CC:

HOPI:

Med Hx:
Last check up:
Reason:
Medical condition:
Medication/ supplement:
Allergies:
Surgeries:
Hospitalisation:

Family HX:

Social Hx:
Smoking:
Alcohol consumption:
Coffee/ tea intake:
Carbonated drinks:
Snacking habit:

Dental Hx:
Last dental visit;
Reason:
Tooth-brushing:
Toothbrush bristle:
Toothpaste:
Flossing:
Mouth rinse:
Appliances:
Parafunctional habit:

Extraoral examination:
Surgical scars/ lesions:
Facial symmetry:
Smile line:
Lip competence:
TMJ:
Lymph nodes:

Intra oral examination

Soft tissue:
Occlusion:

BPE:

Treatment plan:
1. Systemic phase:
2. Urgency phase:
3. Preparatory phase:
 4. Restorative phase:
5. Elective phase:
6. Maintenance phase:

Pain History
Questions to ask
1. Is there a tooth that's bothering you?
2. Are you experiencing pain
3. How would you rate the pain from 1 - 10 - 7/10
4.How long has this pain been present?
5. When did you first experience pain
6. Is the pain now you're having different from the pain you had before the previous treatment?
7. When do you feel this pain?
8. is it a constant psin , if not describe when or how it occurs and how long it might last
9. has the pain occured more frequently or lasted longer in the past few days or weeks
10.is the pain stimulated by something hot or cold
11. is the a time of the day when the pain seems to be worse
12. does the pain awaken you at night - NO
13. how would you describe the pain, dull shap or electric like - DULL
14. have you noted any swelling, do you feel swollen at any area
15. is there an area of your face that is tender to touch
16. are there any teeth that hurt or are uncomfortable when you chew or after you have eaten?
17. do any of your teeth feel lose, or are you biting on any tooth sooner than other teeth

Examination to do :
Heat, cold, ept, air blow
Tender to percussion - vertical and horizontal
palpation
pocket depth
mobility