MASTER TABLE

Name of the Patient : _______________________________

Age/Sex :

__________________
OPD No.: _____________________

Ortho No.: __________________________

Treating Doctor: ______________________________________

Start of Retraction : ______________________

Group: _________________

End of Retraction ____________________

Side Irradiated ___________________

S. No.

Measurement At
Starting of retraction
1 month after retraction
3 months after retraction

Date of Irradiation

Left

Right

6 months after retraction / end of retraction