Professional Documents
Culture Documents
College of Dentistry
Department of Pediatric Dentistry
PERSONAL HISTORY
Pt Name: . Gender:
Age: .. Date of Birth:
Address: Telephone number: ...
CHIEF COMPLAINT
MEDICAL HISTORY
Yes No
( ) ( ) Is your child receiving medical treatment at present ?....................................
( ) ( ) Is your child currently taking any medication? ....................................
( ) ( ) is your child allergic to any medications (e.g. Penicillin) or any other
substance?
( ) ( ) Has your child ever been hospitalized ?....................................................
Has your child had problems with the following: Yes No
Yes No
Yes No
( ) ( ) Cardiovascular
( ) ( ) Bleeding
( ) ( ) Asthma
( ) ( ) Hepatitis/Jaundice ( ) ( ) Diabetes
( ) ( ) Seizures/Epilepsy
( ) ( ) Kidney/Renal
( ) ( ) Speech
( ) ( ) Other
Additional information or any explanation:
DENTAL HISTORY
Yes
( )
( )
( )
No
( ) Is this your childs first dental visit?
( ) Has your child ever had unfavorable dental experience?
( ) Does your child brush his/her teeth?
If yes how many times?{.} per
( ) ( ) Does your child use dental floss? If yes how many times?{.} per
( ) ( ) Does someone assist your child with cleaning the teeth?
( ) ( ) Has your child ever taken Fluoride supplements/Vitamins with Fluoride?
( ) ( ) Does your child have/had sucking habit or any abnormal habit (e.g. nail
biting)?
Taibah University
College of Dentistry
Department of Pediatric Dentistry
DIETARY HISTORY
* Number of main meals
{.} per
* Number of snacks
{.} per
* Number of fresh vegetables
{.} per
* Number of fresh fruits
{.} per
* Number of carbonated or soft drinks
{.} per
* Number of sweets, candy, chocolate or other food containing sugar
{.} per
* Other............................................................................... {.} per
CLINICAL EXAMINATION
Extra-Oral Examination
Intra-Oral Examination
Head/ Face
............
Neck /Nodes
............
Eyes
............
Lips
............
Skin/Hair
............
Other Findings...............................
FUNCTIONAL ASSESSMENT
Breathing:( ) Nose
TMJ: ( ) Normal
Mandibular movement: -
( ) Mouth
( ) Clicking
( ) Normal
( ) Both
( ) Pain
( ) Deviation
PERIODONTAL EVALUATION
( ) Healthy
None
Plaque
Calculus
Staining
( ) Gingivitis
Slight
( ) Periodontitis
Moderate
Heavy
Taibah University
College of Dentistry
Department of Pediatric Dentistry
OCCLUSION
Type of dentition:
Molar Relationship:
2nd Primary Molar
Canine Relationship:
1 Permanent Molar
R ( ) L ( ) Class I
R ( ) L ( ) Class II
R ( ) L ( ) Class III
st
R ( ) L ( ) Class I
R ( ) L ( ) Class II
R ( ) L ( ) Class III
Midline:
( ) Normal
Deviated :
R( ) L( )
Overbite
Open bite: .
Taibah University
College of Dentistry
Department of Pediatric Dentistry
DMF =..
def =..
dmf =..
( ) Moderate Risk
( ) High Risk
DIAGNOSIS
Diagnosis of Chief Complaint:
.
Diagnosis of other Dental Conditions:
Taibah University
College of Dentistry
Department of Pediatric Dentistry
TREATMENT PLAN
Visit
Number
Tooth/ Teeth
to be treated
Procedure to be done
Notes
Additional comments: .
..
..
Supervisor`s Signature: ..
Date: .