OPD DENTIST ASSESSMENT (PEADS)

Patient Name: _________________________________ MR NO: _________________

DOB: ____________________
Sex:__________________ Age: ____________________

OPD DENTIST ASSESSMENT (PEADS)

DENTIST ASSESSMENT

HISTORY:
CHIEF COMPLAINT:

HISTORY OF PRESENT ILLNESS:

PAST MEDICAL, DENTAL & SURGICAL HISTORY:  INSIGNIFICANT

FAMILY HISTORY: (Including: Social/Psychological Factors)  INSIGNIFICANT

MEDICATION HISTORY: Prescription/ Non Prescription / Herbal/ Vitamin  No  Yes, Please specify below
MEDICATION NAME DOSAGE FREQUENCY FORM LAST DOSE
1.

2.

3.

4.

5.

REVIEW OF SYSTEMS/ PHYSICAL EXAMINATION: ( in the appropriate box, describe if abnormal)

GENERAL EXAMINATION & SYSTEM REVIEW:
Negative Positive Comment
Head & Neck
CNS
CVS
Resp.
GIT
Genito-Urinary
Skin
Endocrine
Others: Please specify
Please elaborate more if any System Review is Positive:

LOCAL EXAMINATION:
Issue date: 01/06/2023 Version 01 Page 1 of 3
Document Reference Number: NWGH/MED/F-018/23
OPD DENTIST ASSESSMENT (PEADS)

Patient Name: _________________________________ MR NO: _________________

DOB: ____________________
Sex:__________________ Age: ____________________

 Oral hygiene status: ……………………………………………………………………..……………

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

 Others, Specify:……………………………………………………………………………………………………………………………………………………...
……………………………………………………………………………………………………………………………………………...………...………...…………

INVESTIGATIONS/ RESULTS:

INITIAL DIAGNOSIS/ PROVISIONAL DIAGNOSIS / PROLEMS LIST

FINAL DIAGNOSIS (“” whichever is applicable)

TREATMENT PLAN: PROCEDURE DONE

…………………………………………………………………… ……………………………………………………………………

…………………………………………………………………… ……………………………………………………………………

…………………………………………………………………… ……………………………………………………………………

DISCHARGE/ FOLLOW UP PLAN

Issue date: 01/06/2023 Version 01 Page 2 of 3

Document Reference Number: NWGH/MED/F-018/23
OPD DENTIST ASSESSMENT (PEADS)

Patient Name: _________________________________ MR NO: _________________

DOB: ____________________
Sex:__________________ Age: ____________________

DISCHARGE INSTRUCTIONS GIVEN:  YES  NO

 Follow-up after days  Advice for surgery  Refer to other services
 Admit to ______________________________  Discharge  Any other instructions: __________________________________
 Health education (Refer to interdisciplinary patient and family education form)

DENTIST NAME/ STAMP: _____________________________ SIGNATURE: ___________________

Date: __________________________ Time: ________________

Issue date: 01/06/2023 Version 01 Page 3 of 3

Document Reference Number: NWGH/MED/F-018/23