REPUBLIC OF YEMEN

UNIVERSITY OF SCIENCE AND

TECHNOLOGY-COLLEGE OF DENTISTRY
5th YEAR
Periodontal surgery

Student name: Group :

Student name: Date :

Patent's name: Age :

Sex : Marital status : Telephone no :
Address: Occupation: Education achievement :

Chief complaint :
History of present illness :
Past dental history :

Past medical history :

Sensitivity or abnormal reaction to : local anesthesia penicillin other
Acquired and/or congenital heart disease Leukemia
Hypertension Hypotension
Diabetes mellitus Renal failure , dialysis > transplantation
Intake of medication Hospitalization
Female only: pregnancy , breast feeding , menopause , menstrual cycle , other:

Treatment :

Side of surgical operation :

Procedure :
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Follow-up :
After 2 days of surgery :
After 1 week of surgery :
After 1 month of surgery :

Final senior signature :

@Edit by Dr .Adnan Al-Ward