-
Sample Record Forms
New Patient Record Form
Date
:
Name............................................................................Reg
No......................
Sex.........................................Age.................................Marital
Status............
Address.........................................................................................................
-
Chief Complaint
- C/o
- Onset
- Duration
- Progress
-
Aggravating / Precipitating
factors
- Relieved by
-
History
-
Past Dental History
- C/o
- Treatment given
- Adverse reaction, if any
-
Past Medical History
- H/o Diabetes Mellitus
- H/o Hypertension and Cardiovascular disease
-
H/o Tuberculosis / Respiratory Disease
- H/o Epilepsy
-
H/o Allergy, Asthma
etc.
- H/o Bleeding disorders
- H/o Medications
-
H/o Blood transfusion,
Hospitalisation and Surgery
- H/o Kidney / liver Disease
-
H/o Trauma –
Head and Neck Injuries
- Menstrual irregularities
-
Pregnancy And Breast
feeding
- H/o any other disease
-
Family History
- H/o Tuberculosis
- Rheumatic fever
- Diabetes Mellitus
- Hypertension
-
Bleeding disorder
- Allergy
- Any other
-
Personal History
-
Occupation :
Income :
-
Habits
- Alcohol......................./ day since....................years
-
Bidi............................/ day since....................years
-
Cigarette .................../ day since....................years
-
Tobacco
Quid/Paan....../ day since....................years
-
Paan Masala................/
day since....................years
-
Clenching and Bruxism
- Oral Hygiene Habit
-
H/o Exposure – Any Primary lesions on skin / mucosa / genital
-
H/o anxiety, tension / nervousness / depression
- Any other
Extra Oral and Intra Oral Examinations
Examination Record Form
-
Examination
- Extra Oral
- General
-
Built-- Well built / Average built / Small
built
- Gait-- Normal / Abnormal
-
Skin-- Scars, Sinus, Pigmentation
-
Nails--
Shape, Pallor, Cyanosis
-
Conjunctiva--
Erythema, Ecchymosis, Pallor
-
Sclera-- Icterus,
Ecchymosis
- Facial symmetry and profile
-
Lips--
Competent / incompetent
-
TMJ
- Normal
- Movement-- absent / reduced / deviation
-
Clicking
- Tenderness
- Dislocation
- Sub-luxation
- Any Referred pain
-
Any Congenital / Post Surgical Defects
- Lymph Nodes
- Abnormality, if any --
Intra Oral
- Teeth
- Teeth present
- Teeth missing
- Mobility
-
Hypoplasia and other
development defects
- Attrition/ Abrasion/ Erosion/ Abfraction
-
Caries
/ filled teeth
- Supernumerary / Supplementary teeth / Over retained teeth
-
Discoloured teeth
- Contact points
- Calculus and stains
- Any Restoration/ Crown/ Bridge
-
PeriodontalStatus
- Gingiva
- Colour
- Consistency
- Contour
- Pockets
-
Frenal Attachment
- Festoons
- Furcation involvement
- Food lodgment
-
Material Alba/ Calculus/ Stains
-
Occlusion
-
Occlusion Angle’s Class I, II, III
- Overjet
- Overbite
- Openbite
- Deranged
- Any occlusal interference
-
Soft tissues
-
Lips
- Normal / any defect
- Competent / incompetent
-
Tongue
- Papilla / Coating
- Movement
- Size
- Lesions, if any
-
Cheek
- Linea Alba
- Parotid Papilla (secretion)
- Lesions, if any
-
Hard Palate
- Soft Palate
-
Floor of Mouth
- Wharton’s Duct Orifices ( secretion)
-
Lingual varicosities
- Edentulous ridge
- Tonsillar and Pharyngeal areas
-
Detailed examination of area of c/c
-
Teeth in the area of chief complaint
- Discoloured
- Caries
- Exposure
- Cracked teeth
- Tooth
-
Pockets
- Mobility
- Vitality
- Percussion
-
Swelling
-
Brief description
- Size
- Shape
- Surface
- Borders
- Consistency
- Colour
-
Temperature
- Tenderness
- Spaces involved--
- Any other
findings
- Provisional Diagnosis
Periodontal Record Form
Name of Patient :..........................................................................................
Age :..................................................................Reg. No.
:.............................
Occupation :........................................................Family Income
:..................
Address :.............................................................Education
:.........................
Chief Complaint :.........................................................................................
Patient’s tooth cleaning habits:.......................................................................
Oral Habits :................................................................................................
Medical History :..........................................................................................
Oral Examination Form
I) General Oral Hygiene Status
Plaque :
Calculus :
Stains :
II) Gingiva
- Colour
- Bleeding
- Consistency
- Shape
- Position
- Surface Texture
- Width of attached gingiva
- Suppuration
-
Any other specific condition
of gingiva
III) Any Oral Lesions
IV) Dentition
- Teeth present
- Occlusion;
- Caries;
- Wasting Diseases
- Furcation Involvement;
- Hypersensitivity /Vitality;
- Restoration / Filled Teeth;
- Mobility;
- Migration;
- Contact Relation;
- Food Impaction;
V) Pockets : (Depth in mms)
8 7 6
5 4 3 2
1
8 7 6
5 4 3 2
1
|
1 2 3 4
5 6
7 8
1 2 3 4
5 6
7 8
|
VI) Probable Etiological factors
VII) Diagnosis
VIII) Prognosis
IX) Any Special Investigations / Consultation / X-rays required
X) Treatment Plan
Treatment Record Form
-
Investigations
- X-Rays
- Blood
- Serology
- Biopsy
- Any other
- X-Ray Report
- Differential Diagnosis
- Histopathology Report
- Final Diagnosis
-
Treatment Plan
- Emergency Treatment
- Planned Treatment
