CASE HISTORY FORMAT

NAME:-
SEX:- FILE NO:-
ADDRESS:- PHONE NUMBER:-

CHIEF COMPLAINT:-
MEDICAL HISTORY:-
DENTAL HISTORY:-

 PROFILE
CONVEX CONCAVE STRAIGHT
 SHAPE OF HEAD
MESOCEPHALIC DOLICOCEPHALIC BRACHYCEPHALIC
 FACIAL DIVERGENCE
ANTERIOR POSTERIOR STRAIGHT
 SHAPE OF FACE
ROUND OVAL SQUARE
 FACIAL SYMMETRY
SYMMETRICAL ASYMMETRICAL
 LIPS
COMPETENT IMCOMPETENT EVERTED
 NASOLABIAL ANGLE
NORMAL ACUTE OBTUSE
 MENTOLABIAL SULCUS
NORMAL DEEP SHALLOW
 TOUNGE SIZE
NORMAL SMALL LARGE
  TONGUE ACTIVITY
NORMAL TONGUE THRUSTING
 T.M.J
NORMAL PAIN CLICKING
 FRENUM
NORMAL ABNORMAL
 PATH OF CLOSURE
NORMAL DEVIATED LEFT DEVIATED RIGHT
 BREATHING
ORAL NASAL ORO-NASAL
PERMANENT DENTITION

8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8

DECIDUOUS DENTITION

E D C B A A B C D E

GUMS- PALATE-
FRENUM-
OVERJET- OVERBITE-
MOLAR RELATION-
CANINE RELATION-

DETAILS OF MALOCCLUSION PRESENT

CROWDING OPENBITE ROTATIONS ANTERIOR CROSSBITE

SPACINGS DEEPBITE PROCLINATION POSTERIOR CROSSBITE
DIAGNOSTIC AIDS
Study models Opg Lateral cephalogram Bitewing radiographs
Occlusal radiographs Photographs

DIAGNOSIS-

TREATMENT OBJECTIVES-

TREATMENT PLAN-

Student signature: Mentor’s signature: