Centro Escolar University

School of Dentistry
Manila*Malolos*Makati
ORAL DIAGNOSIS FORM

ACR - model cast (CD)

Name:________________________________________________________Home Address_______________________________________________
Birth Date:_______________________ Age: ___________ Sex:__________ Ht.: __________ Wt.:__________ Civil Status___________________
Home Tel.No.:________________ Cell Phone No.:_________________ Nationality:___________Occupation:___________ Religion:_____________
Case History
A. Chief Complaint/s:
"Wala na ko ngipin, ang hirap ngumuya."
1. _____________________________________________________________________________________________________________________
2. _____________________________________________________________________________________________________________________
3.______________________________________________________________________________________________________________________
4. _____________________________________________________________________________________________________________________
Upon consultation, the patient complained of having no dentures since December 2019, and difficulty in eating due to complete loss of teeth.
B. History of Present Illness:_________________________________________________________________________________________________
There are no noted abnormalities regarding the patient's gingiva and ridges. The last dental visit was December 2019 for tooth extraction.
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
C. Past History: Mark (/) if any of conditions are present and (X) if none.
Medical
X Rheumatic Heart Disease X Asthma X Stomach Ulcers X T.B.
X Myocardial Infarct X Diabetes X Kidney Disease X Hypertension
X Cerebro-Vascular Accident X Liver Disease X Pregnancy X Hypotension
X Allergy specify: Other Illnesses:N/A Medications currently taking: N/A
Dental:
Previous Extraction: _______ Yes ______ No December 2019
If yes when?______________________________________________________________
Denture: _________ None _________ Upper: Type_________________________________ since_________________________________
_________ None _________ Lower: Type_________________________________ since_________________________________
I certify that all informations disclosed are true and correct.
Conforme:
Clinical Examination ACR - model cast (CD) | 02/01/2021
______________________________
A. Extraoral Printed Name and Signature/ Date
Head: ____ Normal ____Abnormal, specify_____________ Eyes: _____ Normal ______ Abnormal, specify_____________
TMJ: ____ Normal ____Abnormal, specify_____________

Vital Signs: 125/81 mmHg

Blood Pressure:__________________ 69 bpm
Pulse Rate:____________ 14 bpm
Respiratory Rate:___________ 36.9 C
Temperature:_________________

B. Intraoral
Lip: ____ Normal ____Abnormal, specify_____________ Palate: _____ Normal ______ Abnormal, specify_____________
Floor of the Mouth: ____Normal ____ Abnormal, specify__________ Tongue: _____ Normal ______ Abnormal, specify____________
Gingiva: ____ Normal ____Abnormal, specify_____________ Deposits: _____ Soft ______ Hard
N/A Class I
Occlusion: _____ N/A Class II _____
_____ N/A Class III N/A
Other Oral Abnormalities noted: _________________________________

C. Mouth Examination

Red Code Blue Code

C- Caries /- Tooth present w/o caries

Abr-Abrasion Am- Amalgam
Fr- Fracture Co- Composite
GI- Glass Ionomer
NO SHADE TF- Temporary Filling
Ex- Indicated for Extraction 55 54 53 52 51 61 62 63 64 65
X- Missing NO SHADE 85 84 83 82 81 71 72 73 74 75
L- Laminates
UN- Unerupted
P- Partially Erupted
JC – Jacket Crown
FPD- Fixed Partial Denture
RPD- Removable Partial Denture

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D. Diagnostic Test:
Tooth No. Mobility Palpation Percussion Test Cavity Hot Test Cold Test Anesthetic Electric
(duration) (duration) Test Pulp Test

Radiographic Interpretation:
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________

Tentative Diagnosis
1. Complete edentulism on both upper and lower
________________________________________________ 4.__________________________________________________
2._________________________________________________ 5. _________________________________________________
3._________________________________________________ 6. _________________________________________________

MARIANO, Marionne M.
Examined by:________________________________________ Jan. 25, 2021
Date:_____________ II
Clinic Level:___________________________

Recommended Treatment Plan

Fabrication of complete denture
1. ________________________________________________ 4.__________________________________________________
2._________________________________________________ 5. _________________________________________________
3._________________________________________________ 6. _________________________________________________

Date Cases/Approved Tooth No. O.D. C.I. Date Cases/Approved Tooth No. O.D. C.I.
01/25/2021 Preliminary Impression
02/01/2021 Study Cast
02/01/2021 Individual Tray

CI’s Remarks:_________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________

Data Privacy Act Statement Policy

Centro Escolar University is committed to respect and value the privacy rights of individuals. We will ensure that all personal data are protected
and processed in accordance with Republic Act No. 10173 or the Data Privacy Act of 2012 and its implementing Rules and Regulations. We
recognize the confidentiality of personal data and adhere to the general principles of transparency, legitimate purpose, and proportionality.
A copy of our full Data Privacy Notice may be obtained from the Office of the Dean and Section Bulletin Board of the School of Dentistry.

Dental Procedure Consent Form

For Minor Patient

I, _____________________________, __________ years of age, ______,

ACR - model cast (CD)
I, _____________________________, ___________ years of age, ______, (Parents’/ Guardian’s Name) (Age) (Sex)
(Name) (Age) (Sex) married/single/widowed, a resident of __________________________________
married/single/widowed, a resident of _________________________________ (Address)
(Address) hereby consent to any dental examination and performance of any or all
hereby consent to any dental examination and performance of any or all procedures, operation, and/or treatment, that are considered necessary to my
procedures, operation, and/or treatment, that are considered necessary to be ward _______________________________ Relation) _____________________
Study Cast and Individual Tray
done at CEU Dental Infirmary specifically, _____________________________ (Name of Patient)
(Procedure) specifically, ___________________________________________________
MARIANO, Marionne M.
by _________________________________________ (Procedure)
(Name of clinician) at CEU Dental Infirmary by ____________________________________
(Name of clinician)
The procedures were clearly explained to me and that I am in the right state
of mind to decide on its merit. Be it known further that whatever the result of The procedures were clearly explained to me and that I am in the right state of
the intervention or treatment may be, none will be liable to any charge that mind to decide on its merit. Be it known further that whatever the result of the
my family, guardian or relative may claim. intervention or treatment may be, none will be liable to any charge that my
family, guardian or relative may claim.
ACR - model cast (CD) | 02/01/2021
________________________________ _________________________
________________________________ ___________________________
Patient’s Printed Name and Sig. /Date C.I.’s Signature and Date
Parents’/ Guardian’s Signature/Date C.I.’s Signature and Date

Copy to student
AAF- DE-005
09/09/2019 Page 2 of 2