UE COLLEGE OF DENTISTRY

ORAL DIAGNOSIS
CLINICIAN:
SECTION: EXAMINATION DATE:

HISTORY REMARKS

I. PATIENT DEMOGRAPHIC DATA

A. Name:
B. Age:
C. Gender:
D. Address:
E. Occupation:
II. CHIEF COMPLAINT/REASON FOR CONSULTATION

III. HISTORY OF ILLNESS/COMPLAINT (fishbone format)

IV. PREVIOUS MEDICAL HISTORY

previous hospitalisation
previous operations
excessive bleeding requiring treatment of blood transfusion
list of medications taken in the last 2 yrs

V. PREVIOUS DETAL HISTORY

when did you last see your dentist, how often do you see a dentist
difficulties on any treatment done before

VI. PERSONAL AND SOCIAL HISTORY

exercise habits
eating habits
alcohol consumption
tobacco use
other pertinent habits/activities

VII. FAMILY HISTORY

FATHER MOTHER SIBLINGS

Living/Deceases(cause) Living/Deceases(cause) No. Living__________

___________ ___________ No. Decease & cause_________
List any pertinent health status of any sibling
age age
present general health status present general health status

GRANDFATHER GRANDFATHER
Living/Deceases(cause) Living/Deceases(cause)
___________ ___________
age age
present general health status present general health status

GRANDMOTHER GRANDMOTHER
Living/Deceases(cause) Living/Deceases(cause)
___________ ___________
age age
present general health status present general health status

OTHERS (UP TO 2ND DEGREE) OTHERS (UP TO 2ND DEGREE)

 UE COLLEGE OF DENTISTRY
ORAL DIAGNOSIS

REVIEW OF SYSTEM

1. CONSTITUTIONAL SYMPTOM
FEVER
WEIGHT LOSS/GAIN
CHRONIC FATIGUE/LACK OF ENERGY
GENERAL MALAISE
RECENT TRAUMA

2. EYES
VISION LOSS

3. EARS, NOSE, THROAT

HEARING LOSS
SINUS PROBLEMS

4. MOUTH

5. CARDIOVASCULAR
HYPERTENSION
CHEST PAIN
SHORTNESS OF BREATH

6. RESPIRATORY
COUGH
SHORTNESS OF BREATH
WHEEZING

7. GASTROINTESTINAL
GERD
DIET (note unhealthy diets if any)
FOOD LIMITATION AND ALLERGIES

8. GENITOURINARY
PREGNANCY

9. MUSCULOSKELETAL
ARTHRITIS
JOINT PAIN
LIMATATION OF MOTION

10. SKIN
SKIN LESIONS
ORAL MUCOSAL LESIONS

11. NEUROLOGICAL
HEADACHE
SEIZURE
FAINTING/LOSS OF CONSCIOUSNESS

12. PSYCHIATRIC
DEPRESSION
ANXIETY
BIPOLAR DISORDERS
SIDE EFFECT OF MEDICATION

13. ENDOCRINE
DIABETIS
THYROID DISORDERS

14. HEMATOLOGICAL
ANEMIA
COAGULATION PROBLEMS
LIVER DISORDER

15. ALLERGIC/IMMUNOLOGICAL
ALLERGY TO MEDICATIONS
SEASONAL ALLERGIES
 UE COLLEGE OF DENTISTRY
ORAL DIAGNOSIS

CLINICIAN _________________________________________ SECTION______________________

DATE OF EXAMINATION______________________________

MIDTERM PRACTICAL ACTIVITY - EXTRA-ORAL PHYSICAL EXAMINATION

PHYSICAL EXAM RESULT REMARKS

GENERAL APPRAISAL (encircle breathlessnes,

any that apply) physical disability,
obvious illness
ROUTINE MEDICAL
EXAMINATIONS:
BLOOD PRESSURE
PULSE RATE
RESIPIRATORY RATE
TEMPERATURE
EXTRA ORAL EXAMINATION
(inspection, palpation, auscultation,
percussion)
HEENT/MOUTH
EYES:
Visual acuity
Binocular vision/blind spot
Eye movement
Other
symptoms:____________________
______
EAR:
Hearing on Right side
Hearing on Left side
NECK:
Thyroid gland
Lymph nodes
SALIVARY GLAND:
Parotid gland R/L
Submandibular gland R/L
TMJ
Maximum opening
Range of motion
Condyle (bi-lateral external)
(bi-lateral in EAC)
MUSCLE OF MASTICATION
(palpation)
Masseter muscle
Temporalis muscle
Mastoid head of SCM
 UE COLLEGE OF DENTISTRY
ORAL DIAGNOSIS

CLINICIAN _________________________________________ SECTION______________________

DATE OF EXAMINATION______________________________

PATIENT TREATMENT PLAN & PROPOSED TREATMENT SEQUENCE

TREATMENT PLAN A TREATMENT PLAN B (ALTERNATIVE)

SYSTEMIC PHASE

ACUTE PHASE

DISEASE CONTROL PHASE

DEFINITIVE PHASE DEFINITIVE PHASE

MAINTENANCE PHASE
 UE COLLEGE OF DENTISTRY
ORAL DIAGNOSIS

REVIEW OF SYSTEM
1. General: Fever, Chills, Sweating, Weakness, Fatigue, Change in wt
2. Skin: rash;itch, pigmentation; bruising; scars; nails-changes in shape, brittleness, pitting; hair-
excess loss, change in texture or distribution
3. Head: Headache, Trauma
4. Eyes: Decreased vision, transient or permanent loss of vision, double vision, spots. pain,
redness, tearing, discharge, sensitivity to light, use of glasses or contact lenses, cataracts,
glaucoma
5. Ears: Hearing loss, ringing, dizziness with subjective feeling of rotation, pain, discharge
6. Nose and sinuses: Bleeding, discharge, obstruction, colds, change in sense of smell, pain
7. Mouth: Pain, lesions; dryness; tongue-soreness, lesions or coating, enlargment; problems
with taste; teeth-pain, extractions, most recent dental exam; gums-bleeding, lesions,
dislocations
8. Throat: Frequent sore throats or tonsillitis, hoarseness, problems with swallowing
9. Neck: pain, stiffness, swelling, lumps, limitation of motion, thyroid enlargement
10. Respiratory system: cough, sputum, hemoptysis, night sweats, shortness of breath,
wheezing, pain with breating, exposure to TB
11. Cardiovascular: Chest pain, shortness of breath with exertion or whinnying down, swelling of
the legs or feet, pounding in chest, irregular or rapid heartbeat, heart murmur, high blood
pressure
12. Vascular system: lower extremity pain with exertion, leg cramps, blood clots, varicose veins,
coldness or change in color of extremity

DEFINITION OF COMMON SKIN/MUCOSAL LESIONS

primary lesions
macules - localized changes in the skin color, non palpable lesion. may be associated with
desquamation or scaling. exemplified in rubeola, rubella, secondary syphiis, rose spots of typhoid
fever
papules - solid and elevated, less than 5mm in diameter, borders and tops may assume various form.
pointed and acuminate lesions occur in insect bits, acne and the physiologic gooseflesh. flat topped
psoriasis, atopic eczema, condyloma datum
plaques - elevated area greater than 5mm, may form from confluent papillose, red scaling plaques are
seen in psoriasis
nodules - solid and elevated depper into the dermis or subcutaneous tissue. usually greater than
5mm in diameter.
wheals - oedema of the skin, circumscribed, irregular and relatively transient. cool varies from red to
pale, depending on the amount of fluid in the skin, ex. urticaria and insect bites, fever, urticaria
vesicles - accumulation of fluid between the upper layers of the skin products an elevation covered by
translucent epithelia that is easily punctured to release the fluid
bullae - accumuation of fluid between the layers of the skin larger than 5mm in diameter, contact
dermatitis, second agree burn, pemphigus
pustules - vesicles or bullae that become filled with pus and tiny abscesses in the skin
cyst - elevated lesions onaining fluid or viscous material appear as papules or nodules
vegetations - elevated irregular growths, when covering is keratotic or dried they are verrucous, when
covered with normal epidermis they are papillomatous
hyperkeratosis - keratotic cells are piled up to produce elevations, calluses are the most common

secondary lesions
scales - thin plates of dried cornfield epithelium cling to the epidermis, partly separated. i.e. psoriasis
and exfoliative dermatitis
lichenification - dry plaque which the normal skin furrows or rhomboid lines are accentuated, i.e.
repeated rubbing of the skin producing hyperplasia of all layers
crusts - plate of dried serum, blood, pus or serum forms upon the surface of any vesicular or pustular
lesions when it ruptures
atrophy - skin is thinned lacking resilience and loss of skin furrows or rhomboid lines. ie senile atrophy,
DLE, insulin lipodystrophy
sclerosis - area of skin in indurated from underlying interstitial inflammation i.e. keloid
erosion - moist surface uncovered by rupture of vesicles or bullae or by laceration from rubbing
fissures - cleavage of the epidermis extending into the dermis
ulcers - depressed lesion results from loss of epidermis and the papillary layer of the dermis
gangrene - extensive destruction of the skin may leave many dead cells that become blackened