Update Dental College& Hospital

Aichi Nagar, Turag, Dhaka

Department of Oral & Maxillofacial Surgery

History Sheet
Personal Details: Reg. No. :
* Name of the Patient : Date :
* Age :
* Sex :
Present Address :
Contract Number :
Chief Complaint:
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History of present illness:

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Past Medical History:

□ Anaemia □ Jaundice □ Rheumatic Fever □ Diabetics
□ Hypertension □ Heart Disease □ Asthma □ Pregnancy
□ Bleeding Disorder □ Gastritis & Ulcer □ Renal Failure
□ Liver Disease □ Previously Major Operation □ Epilepsy
□ Others

Drug taken before:

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History of Allergy:
● Allergic to any drug :
● Allergic to foods or substances :

Personal and Family History: ……………………………………………………………………………..

General Examination: Systemic Examination:

 Anaemia:
 Cardiovascular System:
 Jaundice :  Alimentary System :
 Cyanosis:  Genitourinary System :
 Oedema: ● Nervous System :
 Dehydration: ● Locomotor System :
 Pulse: ●
 Blood pressure: ●
 Respiratory rate: ●
 Temperature
 ● Local Examination:
 Extra Oral Examination:
 Facial Appearance:
 Swelling:
 T.M Joint:
 Lymph node:
 Salivary gland:
 Trismus:
 Others:

 Intra Oral Examination:

 Mucosa:
 Gingiva:
 Plaque & calculus:
 Mobility:
 Missing tooth:
 Description of effected area:
 Others:

Salient Feature: ……………..………………………………………………………………………

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Provisional Diagnosis:
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Investigation:..........................................................................................................................................
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X-rayfinding:
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Other Investigation:..………………………………………………………………………………

Diagnosis:……………………………………………………………………………………………..
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 Treatment Plan:
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Treatment Performed (Procedure):

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Medication(Rx):
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Instruction:
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Follow up:
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Signature of the student Signature of the Supervisor Signature of Head of the
Department