Họ và tên sinh viên: ………………………………………….

Lớp: …………
Hội đồng thi: …………………………………………. Ngày thi:………………
Thời gian bắt đầu: ……………………. Thời gian kết thúc: ………………….

ĐIỂM Giảng viên Giảng viên Giảng viên

chấm thi 1 chấm thi 2 chấm thi 3

BÁO CÁO KHÁM, CHẨN ĐOÁN, LẬP KẾ HOẠCH ĐIỀU TRỊ

(CHỮA RĂNG NỘI NHA)
BỆNH NHÂN________________________________ Giới tính___________Tuổi_________
1. Lý do đến khám: …………………………………………………………………..
2. Bệnh sử, tiền sử:
Bệnh sử: ………………………………………………………………………………………….
……………………………………………………………………………………………………
……….
……………………………………………………………………………………………………
……….
……………………………………………………………………………………………………
……….
……………………………………………………………………………………………………
…………………………………………………………………………….
…………………………………………………………………………………………………….
…………………………………………………………………………………………………….
……………………………………………………………………………………………………..
……………………………………………………………………………………………………
……………………………………………………………………………………………………
……………………………………………………………………………………………………
……………………………………………………………………………………………………
……………………………………………………………………………………………………
……………………………………………………………………………………………………
……………………………………………………………………………………………………
Tiền sử y khoa …………………………………………………………………………………..
……………………………………………………………………………………………………
……………………………………………………………………………………………………
Tiền sử nha khoa …………………………………………………………………………………
……………………………………………………………………………………………………
……………………………………………………………………………………………………
3. Thăm khám lâm sàng
Toàn thân ………………………………………………………………………………..……….
………………………………………………………………………………………………..……
…………………………………………………………………………………………………..…
Khám Răng hàm mặt
Khám ngoài mặt ……………………………………………………………………………………
………………………………………………………………………………………………….......................
...........................................................................................................................................................
...........................................................................................................................................................
.
Khám khớp thái dương hàm……………………………………………………………………….
………………………………………………………………………………………………….......................
.
………………………………………………………………………………………………………………….
Khám trong miệng ( mô mềm, khớp cắn, mô nha chu, răng)………………………………………
……………………………………………………………………………………………...............................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
…………….........................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
..........................................................................................................................................................
Sơ đồ răng

Ghi chú ký hiệu: …………………………………………………………………………………………...

…………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………
………………………………………………………………………………………………………………….
Các thử nghiệm

Thử nghiệm R… R…
Gõ
Nhiệt nóng/ lạnh
Lung lay
Khác:……..

Phim 1: loại phim

………………………………………......................................................................................................
…………………………………………………………………………………………………………...
.......................................................................................................................................................
 .......................................................................................................................................................
.......................................................................................................................................................
...
.......................................................................................................................................................
.

Kết quả Xquang (nếu có) Thân Răng, Chân răng, Mô quanh chóp Cấu trúc lân cận

4. Biện luận, Chẩn đoán

..........................................................................................................................................................
……………………………………………………………………………………………………
……………………………………………………………………………………………………
……………………………………………………………………………………………………
…………………………………………………………………………………………………….
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
..........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
..........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
..........................................................................................................................................................
5. Kế hoạch điều trị
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
..........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
..........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
6. Tiên lượng và theo dõi
………………………………………………………………………………………………….......
...........................................................................................................................................................
.........................................................................................................................................................
……………………..
…………………………………………………………………………….......................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
...........................................................................................................................................................
......................................................................................................................