Dental Exam

OVERALL_INSTRUCTIONS

Remove any sections if no information present, when writing tooth numbers write as 17, 54, etc. and not 1-7, 5-4.

Chief Complaint

[Patient's stated reason for visit]

Template

Chief Complaint: [Patient's stated reason for visit] History of Present Illness: [Description of onset, duration, location, and character of dental symptoms] [Associated symptoms such as pain, swelling, bleeding, sensitivity] [Aggravating or relieving factors] [Previous dental treatments related to current complaint] Past Dental History: (hyphenated list) - [Previous dental procedures] - [History of dental trauma] - [Orthodontic treatment] - [Periodontal disease] - [Other relevant dental history] Medical History: (hyphenated list) - [Chronic medical conditions] - [Recent hospitalizations or surgeries] - [Relevant systemic diseases] Medications: (hyphenated list) - [Medication name, dose, route, frequency] Allergies: (hyphenated list) - [Drug allergies] - [Latex allergy] - [Other relevant allergies] Social History: (hyphenated list) - [Tobacco use: type, amount, duration] - [Alcohol use: type, amount, frequency] - [Recreational drug use] - [Occupation] - [Living situation] Dental Examination: (hyphenated list) - [Vital signs if taken: HR: #, BP: #, T: #, RR: #, O2 sats: #%] - [Extraoral exam: findings] - [Intraoral soft tissue exam: findings] - [Teeth: findings by tooth number or region] - [Periodontal exam: probing depths, bleeding, recession] - [Occlusion: findings] - [Radiographic findings if available] Investigations: (hyphenated list) - [Radiographs: type and findings] - [Other diagnostic tests] Assessment: (hyphenated list) - [Primary dental diagnosis -- state plainly whether the finding is present, absent, or resolved; avoid ambiguous phrasing] - [Secondary diagnoses] - [Differential diagnosis if applicable] Plan: (hyphenated list) - [Immediate treatment provided] - [Planned procedures] - [Medications prescribed] - [Patient education and counselling] - [Referrals to specialists] - [Follow up plan, including any pending biopsy/pathology/investigation results, the plan once they are received, and any contingent next steps discussed if findings are abnormal] - [Return precautions]