Patient Number: Date: / / 20

Patient Name:
Age:
Gender: □Male □Female
Nationality: □ Iraqi □ Arabic □ Foreign.
Occupation: □ Jobless □ privately □Employer □ Housewife.
Marital Status: □Single □Married □Widow □Divorced.
Education: □Illiterate □Literate □Primary □Secondary Preparatory □Graduate
□Postgraduate
Address: □City center □District □Township □Village
□Other province □other country
Income: □Low □Middle □Good □ High.
Food Habits: □Vegetarian □Normal □Drink milk □Chewing Gum □Like Nuts
□Like sweets.
Tel. Number:
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MEDICAL HISTORY:
HOSPITALIZATION: □No □Yes □CCU □ (Blood, Plasma, Factors) Transfusion □Surgery
Type:…………………...
MEDICATIONS: □Non □ Antibiotic □Analgesic □Antihypertensive □Insulin □Anti-hyperglycemic
□Steroid □Aspirin □NSAID □Beta-blocker □ Glycerin Trinitrat □Cytotoxic
□Anti-convalescent □Anti-Coagulant □Anti-Depressant Others:……………………
ALLERGY: □No □Yes □Penicillin □Sulfanilamide □Cephalexin □Food □Other………………
CVS:
 Ischemic Heart Dis. □yes □no.
 Hypertension □yes □no.
 Myocardial Infarction □yes □no.
 Arrhythmia □yes □no.
URINARY TRACT DIS.: □no □yes □Renal stone □Renal Infection □Renal Failure
□Kidney Transplant.
RESPIRATORY DIS.: □no □yes Influenza □Bronchitis □Asthma others………………………...
CNS Dis.: □no □yes □CVA □Meningitis □Epilepsy □Multiple Sclerosis
□Parkinson Dis. □Brain Tumor □ Schizophrenia □Depression Others…………………
GIT. : □no □yes □Dysphagia □Ulcer □Loss of appetite □Abdominal Pain □Gallstone
□ Others
SKELETOMUSCULAR DIS. : □no □yes □Osteoarthritis □Rh. Arthritis □Gout □ Rh. Fever
Others …………….
BLOOD AND LYMPHATIC DIS.: □no □yes
Anemia □SCA □Thalassemia □G6PD □Iron Deficiency Anemia □Vitamin B12 Anemia
□Folate Deficiency □Aplastic Anemia
Bleeding Tendency □Hemophilia (missing factor VIII) □Chrisms’ Dis. (missing factor IX)
Blood Descriesa □Lymphoma □Leukemia Others………………...
ENDOCRINE SYSTEM DIS.: □no □yes
Pancreas Dis. □ IDDM □NIDDM Other…………….
Thyroid Dis. □hypothyroidism □Hyperthyroidism
Adrenal Dis. □Addison ’s disease □Cushing's syndrome
Parathyroid Dis. Hyperparathyroidism Others………………………..
INFECTIOUS DIS.: □no □yes □Hepatitis □TB □Pneumonia TB □AIDS □ H1N1
□Skin infections Others…………………………...
PREGNANCY: □no □yes Number of pregnancy □History Of Abortions □Uterine Contraction
□1 st trimester □2nd Trimester □3rd trimester
LACTATION: □no □Yes □Age of baby.
FAMILY HISTORY: □non □Diabetes □Heart Dis. □Renal Dis. □Congenital Abnormality
□Sickle Cell A. □Hemophilia Others……………………………..
HABITS: □Non □Brushing Technique □Thumb sucking □Lip Sucking □Tongue thrust
□Mouth breathing □Bruxism □Clenching □ Smoking □Alcoholic □Addict
Others………………….
VITAL SIGN: PR………, RR□………., BP…………………, Temp…………………..

…………………………………………………………………………………………………………………………………………………………
DENTAL HISTORY
CC: □pain □Swelling □Ulcer □Sensitivity □Bleeding □Itching □Burning □Discomfort □Truisms
□ Mobility □ Bad Oder (Halitosis) □For Esthetic □For Prosthetic □For Orthodontic □ Prophylactic
□Checkup □Atypical facial pain.
HPI:
 CHARACTERESTIC of pain: □Non □Dull □Throbbing □Shooting □Aching □Sharp
□Stabbing □Atypical Others……………………….
 SEVERITY: □Non □Mild □Moderate □Sever.
 DURATION: □Non □Hours □One night □Day □Week □Month □Year .
 ONSET: □Non □Sudden □Chronic □Continuous □Intermittent.
 SITE: □ULQ □URQ □LLQ □LRQ
 EFFECTING FUNCTION: □Non □Brushing □Shaving □Washing of face □Sleep
□Movement of Head Others………………………………...
 SPREAD OF PAIN: □Non □Referred □Radiated Others…………………….
 AGGRAVATING FACTORS: □Non □Cold □Hot □Sweet □Chewing □Breathing
Others…………………
 RELIVING FACTORS: □Non □Brushing □Mouth wash □analgesic □Antibiotic
□Topical Application Others…………………….
 ASSOCIATED SIGN & SYMPTOMS: □Non □Fever □Pallor Swelling □Bleeding □Truisms
□Discharging □Weakness □Sweeting Other……………
 RECURRENCE : □No □Yes □Number.
 PATIENT WITHOUT PAIN GIVE HISTORY OF: □Old Caries tooth □Old Retain Root □Old Fracture Tooth
□ A decision of Specialist to Extract Sound Tooth or Impacted.
 …………………………………………………………………………………………………………………………………………………………

EXTRA ORAL EXAMINATION

 FACE : □Symmetrical □Asymmetrical Why…………………………………………………………………………………………….
 Hair distribution: □Normal □Abnormal why……………………………………………………………………………………...
 Skin : □NAD □Pallor □Acne □Freckles □Scare □Nevus □Pigmentation □edema
□Mass □ Rashes □Sores □Itching □Others
 Eye : □NAD □Position + Aliment □Exophthalmia □Strabismus □White sclera □ Yellow sclera
□Red sclera □Blind □Loss eye □ Others
 Enlarged LN : □ NAD □Sublingual □Submental □Submandible □ Preauricular
□Postauricular □occipital □ Buccal ( facial ) □Tonsillar
□ Anterior cervical □Posterior cervical
□ Unilateral □Bilateral □Tender □Others
 TMJ : □NAD □Mouth opening
□PAIN → □Unilateral □Bilateral
□SOUND (Clicking) Detected by→ □Hearing □Palpation □Auscultation
□MUSCLE SPASM → □Unilateral □Bilateral
□Masseter □Medial pterygoid □Lateral pterygoid □Temporalis
□Deviation to → □Right □Left □Mid movement of mandibular opening.

…………………………………………………………………………………………………………………………………………………………………
INTRA ORAL EXAMINATION
 OCCLUSION : □Cl l □Cl ll □ div.l □Cl lll
□ div.ll
 LIPS :
Competence □Yes □No
Color □Pink □Red □White □Blue □Black
Texture □Soft □Hard □Nodulated □Swelling □Fissure □Cracks □Ulcer □Plaque + scar
□Others
 MUCOSA :
Color □Pink □White □Red □Blue
Texture □Soft □Hard □Nodular □Swelling □Check bite □Ulcer
□Fordyce’s granules □Others
 TONGUE :
Color □Pink □White □Brown □Black hairy □Yellow □Smooth &Glazy
Texture □Soft □Hard □Fixed □Fissure □Cracks □Ulcer □Swelling
□Geographic tongue
 FLOOR OF THE MOUTH :
Color □Pink □Red □Blue □White
Texture □Soft □Hard mass □Swelling □Ankylo- glossia □Others
 PALAT :
Color □Pink □Red □White □Blue
Texture □firm □Soft □Hard □Ulcer □Swelling
 TONSILE Area:
Color □Red □Brown □Yellow
Swelling □Non □Hard □Soft □Others
 POST PHARNGIAL :
Color □Pink □Red □White
Swelling □Yes □No
□Others

 GINGIVA :
Color □Pink □Red □White □Brown □Blue
Contour
□Scalloped □Flat
Shape □Knife edge □Round □Lost of interdental papilla
Consistency
□Firm □Edematous □Bony hard □Thin Biotype □Thick Biotype
Swelling
□Free gingiva □Attached gingiva (Gum boils) □Interdental papilla
□Hard □Soft □Brown □Nodular
□Bleed easily □Painful □Sinus discharging bus
Stippling □Yes □No
Recession □Cl l □Cl ll □Cl lll □Cl lV
 PDL : □NAD □Pocket □Discharge □Mobility □Others

 BUCCAL VESTIBUL :
Color □Pink □Red □White □Blue □Brown
Depth □Normal □Shallow □Deep
Swelling □Soft □Firm □Bony Hard □Fluctuant □Fixed □Mobile □Tender
□Not Tender □Discharge
Ulcer ♊□Smell □Large □Multiple □Painful □ Painless

 TEETH:

♊♊♊♊♊♊♊♊ ♊♊♊♊♊♊♊♊
♊♊♊♊♊♊♊♊ ♊♊♊♊♊♊♊♊
Select one of the following to each surface:
S- Sound , M- Missing , F- Filling , D- Caries , ♯- Fracture , Mo.- Mobile , RR- Retaind Root

 TRAUMATIZED TEETH □Extruded □Intruded □Displaced □Avulsed Others………………………………………

 EXAMINATION TO THE TOOTH TO BE EXTRACTED : No. and site of the tooth………………….

Vertical percussion □Non □Yes □No
Horizontal percussion □Non □Yes □No
Probing □Non □Yes □No

 TYPE OF RADIOGRAPH : □Perapical □Occlusal □OPG □ConePem CT □True lateral

□Lateral oblique □Post-anterior □Occipitomental □CTS
□MRI

 RADIOGRAPHICAL FINDING : □Non

 □Caries □Fillings □Complete root □Open apex □ Resorbsion of intercepted bone □Dilated apical PDL
□Destruction of lamina Dura □Radiolucency □Radio opacity □Radiolucency + opacity
□Radiolucency with radiopaque line □Multiple radiolucency □Multiple radio opacity □Fracture Tooth
□Fracture Alveolus □Fracture Mandible □Fracture Maxilla □Impacted □Extra Tooth Others……………..

 MEDICAL COSULTATIONS : □Non □Physician □Surgeon □E.N.T □Ophthalmic

□Psychiatric □ Neurosurgeon □Others……………………………
 BIOBSY : □Non □Incisional □Excisional □FNA □Puncture □Swap □Aspiration
 INVESTIGATION : □Non □FBS □RBC □ESR □Hb □WBC □Platelet □BT □CT
□INR □Others
 EMERGINCY TREATMENT : □Non □Extraction □Medical treatment □Drainage □Reduction + Fixation
□Suturing □Refer to hospital □Others ……………………………………
 DIGNOSIS : □Ch.pulpitis
□Acute pulpitis
□Symptomatic Ch.periapical periodontitis (abscess)
□ Symptomatic Acute periapical periodontitis( abscess)
□Asymptomatic Periapical periodontitis (granuloma)
□Periodontitis □Impacted □Malpposed □Supernumerary □Delay exfoliation
□Dental Fracture □ Dento-alveolar Fracture □Necrotic pulp □Attrition □Sound for
orthodontic.

 STUDENT NAME:

 STARTING: SUPERVISE NAME:

Date: \ \
 Surgone Notes:
………………………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………………………………
 Evaluation:
1. IC : (Max. 1)
2. CH: (Max. 3)
3. Anasth. ( Max. 2)
4. Extrac. (Max. 2)
5. P.O.C. & Instraction (Max. 2)

 FINISHING: SUPERVISE NAME:

Date: \ \

 Assistant in surgery :
 Names of Students:
1. 2. 3. 4.

5-

 Name of Operator:
 Type of surgery: