PARTICULARS OF THE PATIENT:

Name of the patient :

Age :
Sex :
Religion :
Marital Status :
Address :
Phone Number :

 CHIEF COMPLAINTS :

 HISTORY OF PRESENT COMPLAINTS:

 PAST ORAL HISTORY:

 VITAL SIGNS:
 Pulse : beats/min
 Respiratory Rate : breath/min
 Blood pressure : mm of Hg
 Temperature : o
F

 MEDICAL HISTORY:

Hospitalization Bleeding disorder Hepatitis

Surgery Diabetes Tuberculosis

Rheumatic fever Anemia Pregnancy

Druge allergy STDs Lactation

CVS
 ORAL HYGIENE ACTIVITIES:
 Brushing
 Inter-dental cleaning

 FAMILY & SOCIAL HISTORY:

 Occupation
 Family members
 Habits

 EXTRA-ORAL EXAMINATION:

VISUAL DIGITAL
 Appearance  TMJ
 Pigmentation  Salivary glands
 Scar marks  Lymph nodes
 Lip-posture
 Facial symmetry
 Swelling

 INTRA-ORAL EXAMINATION:

 Oral Mucosa:
 Tongue:

 Dorsal Surface:
 Ventral Surface:
 Lateral Boarder:

 Frenulum attachment:
 Gingiva:
 Free gingiva:
o Marginal gingival
o Interdental gingival

 Attached gingiva

 PLAQUE
 Marginal:
 Interproximal:

 CALCULAS:
 Supra-gingival:
 Sub-gingival

Number of Teeth Present:

8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8
8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8
 Caries:  Attrition:
 Pain on percussion:  Abrasion:
 Hypersensitivity:  Erosion:
 Other Factor:  Pulpal lesion:
 Occlusion:
 Radiography (X-Ray):
 Periodontal Pocket depth:

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

 Fl:
 Mobility:
 Drifting:
 Spacing
 Crowding

SALIENT FEATURE
DIAGNOSIS WITH ETIOLOGY

TREATMENT PLAN

o OHI
o Scaling
o Polishing

MAINTENANCE:

Teacher’s Signature