DENTAL RECORD CHART

Name: Gender: M/F

Age: Date:
Cellphone No.: Address:

STATUS
RIGHT LEFT
55 54 53 52 51 61 62 63 64 65

TEMPORARY
TEETH

18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
PERMANENT
TEETH

48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38

TEMPORARY
TEETH
85 84 83 82 81 71 72 73 74 75
STATUS
RIGHT LEFT

Legend: Condition Restorations & Prosthetics Surgery

 - Present Teeth Am - Amaigam Filling X - Extraction due to Caries
D - Decayed (Caries Indicated for Filling) Co - Composite Filling XO - Extraction due to Other Causes
M - Missing due to Caries JC - Jacket Crown
MO - Missing due to Other Causes Ab - Abutment X-ray Taken:
Im - Impacted Tooth Att - Attachment ___ Periapical (Tth No.: ____)
Sp - Supernumerary Tooth P - Pontic ___ Panoramic
Rf - Root Fragment In - Inlay ___ Cephalometric
Un - Unerupted Imp - Implant ___ Occlusal (Upper/Lower)
S - Sealants ___ Others: ___________________
RD - Removable Denture ___________________

Periodontal Screening Occlusion Appliances: TMD

_____________ Gingivitis
_____________ Early Periodontitis
_____________ Moderate Periodontitis
_____________ Advanced Periodontitis
_____________ Class (Molar)
_____________ Overjet
_____________ Overbite
_____________ Midline Deviation
_____________ Crossbite
_____________ Orthodontic
_____________ Stayplate
_____________ Others ________
___________________________
___________________________
___________ Clenching
___________ Clicking
___________ Trismus
___________ Muscle Spasm
Name: Age: Gender: M/F _________

TREATMENT RECORD

Tooth Procedure Amount Amount Next

Date Dentist/s Balance
No./s charged Paid Appt.