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Patient Title :
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Mr.
Mrs.
Ms.
Md.
Mohd.
Prof.
Dr.
Engr.
Adv.
Master
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PiD No. (Left Blank for Auto ID):
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Patient First Name :
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Last/Sur Name:
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Gender :
--Select Gender--
Male
Female
Boy
Girl
Others
Age/ Date of Birth (YYYY-MM-DD):
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Valid Mobile No.:
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Alternate/Family Mobile No.:
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Valid e-Mail ID:
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Father/Mother/Guardian:
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Address:
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Ref. by:
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C/C (Chief Complain):
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Aesthetic Purpose
Bleeding from
Bleeding from Gum
Broken Crown
Broken Crown- Artificial
Broken Tooth
Cant Bite
Cant Chew
Caries
Check up
CHEST PAIN
Chewing Difficulty
Delayed Eruption of Teeth
Denture
Discoloration
Discomfort
Dislodgement
EFIGASTRIC PAIN
Filling Dislodgement
Food Impaction
Foul Smelling/Odour
G.C.: Gross Caries
GENERALIZED BODYACHE
Gum Swelling
Halitosis
Intra Oral Sensitivity
IrregularTeeth
IrregularTeeth & Gap
LBP, HTN, HYPOTHYROIDISM
Limitation of Mouth Opening
Missing Tooth-
None
Normal Shedding
Pain
Pain & Swelling on
Pain and Sensitivity
Pain during Chewing
Proclination
RCT Complication
Retained Root
Routine Checkup
Sensitivity
Sensitivity to Cold
Sensitivity to Hot
Sensitivity to Swear
Smell or Taste
Staining+++
Tooth Cavity
Tooth Mobility
Tooth Spacing
Unusual
Unusual Sound
UTI, RBS
Want to Clean
Want to Remove
Want to Replace Missing Tooth
C/C:... ... ... ...
Set...
H/O (History of):
*
Abrasion
Abscess on
Acute Pulpitis
Apthous ulcer
Attrition
BDR
Calculus+
Calculus++
Calculus+++
Caries on
Chronic Pulpitis
Cyst on
Discolouration of tooth
Erosion
Extrusion
Fracture Crown on
Fracture on
Gingival Hiperplasia
Gingivitis
G.C.- Gross Caries
Sensitivity
RCT: Root Canal Treatment ™
Tooth Missing
Gum Swelling Diseases
Swelling of interdental papilla
Irreversible Pulpitis
HTN
Pain
DM
Periodontitis
Necrosis with Acute Apical Abscess
Advanced periodontitis
BDR with Symp. Periodontitis
Necrosis followed by/due to trauma
Dislodgement of Crown
PD- Partial Denture
FPD- Fixed Partial Denture
Kennedy on
Normal Shedding
Symtomatic Apical Periodontitis
Irreversible Pulpitis with Symptomatic Apical Periodontitis
Cavity (Dentin)
Previously treated with Periodontal Absess
Previously Treated (Inadiquate meriel root with Symp. Apical Periodontitis)
Pulpitis
Symptomatic Irreversible Pulpitis with Apical Periodontitis
Mild Periodontitis
Symptomatic Irreversible Pulpitis
Acute Pericoronitis
Generalized Attrition with Reversible Pulpitis
Acute Irreversbible Pulpitis
Comp. Hypersensitivity
Previously Initiated with Symptomatic Apical Periodontitis
Acute Irreversible Pulpitis
Broken Crown
Cold- Sensible Irreversible Pulpitis
Mild/Moderate Periodontitis
Impacted Canine
Necrosis with Symtomatic Apical Periodontitis
Food impaction
Previously Initiated Therapy
Previously Treated
Pulp Necrosis
Condensing Osteitis
Apical Abscess (Chronic)
Apical Abscess (Acute)
Asymptomatic Apical Periodontitis (Chronic)
Symptomatic Apical Periodontitis (Acute)
Dental checking
Previously Initiated
Acute Necrosis with Symp. Apical Periodontitis
Class 1 modification 1 (Tramatic bite)
Binax with Antarior Crowding
Horizontal Inspaction
Crown Commuting
Class I Cavity
TMJ dysfunction symdrome
Class II Cavity
Verticle Crown Fracture
Previously Done RCT
Open Heart Surgery--Ecospirin
Retained Bone Chips in Extracted Side
Multiple BDC
Previously initiated with Apical Abscess
Traumatic Ulcer
Detached FPD
Reversible Pulpitis
Irreversible Pulpitis with Apical Periodontitis
Cleaning of Teeth
Diastona b/w
Fixed PFD
Halitosis
Pulse: BP: Heart:
Calculus & Staining +++
BDC
RCT/Resto.
Initially Trreated
Roots are Seperated
Pits & Fissure Caries
Hypertension
Palpation : NAD
Pescium: NAD
Mobling/Tooth Mobility: No
NAD (No Abnormality Detected)
NAD (No Apparent Distress)
NAD (No Acute Disease)
NAD (No Appreciable Disease)
NAD/YES/NO
Visual Hygiene: Collagen/Colchgen
Palpation: NAD
Periodont: NAD
Malocclusion
Class I Cavity- Malocclusion
Proximal Cavity
new1
new2
Pulpitis with Pulp Caries
Generalized & Gum Hyperplasia
Partially Impacted
Necrosis with Alveolar Abscess
Kennedy Class III- Modification
Chronic Periodontitis
Sub-Gingival Calculus
BDR with Symp. Periodontitis
BDR with Acute Alveolar Abscess
Acute Alveolar Abscess
Class II Division I
Binax with Oral Thrush
Complete Denture: Upper/Lower
Partial Denture: Upper/Lower
Ext.: Extruction
Set...
D/X (Diagnosis):
*
Abrasion
Abscess on
Acute Pulpitis
Apthous ulcer
Attrition
BDR
Calculus+
Calculus++
Calculus+++
Caries on
Chronic Pulpitis
Cyst on
Discolouration of tooth
Erosion
Extrusion
Fracture Crown on
Fracture on
Gingival Hiperplasia
Gingivitis
G.C.- Gross Caries
Sensitivity
RCT: Root Canal Treatment ™
Tooth Missing
Gum Swelling Diseases
Swelling of interdental papilla
Irreversible Pulpitis
HTN
Pain
DM
Periodontitis
Necrosis with Acute Apical Abscess
Advanced periodontitis
BDR with Symp. Periodontitis
Necrosis followed by/due to trauma
Dislodgement of Crown
PD- Partial Denture
FPD- Fixed Partial Denture
Kennedy on
Normal Shedding
Symtomatic Apical Periodontitis
Irreversible Pulpitis with Symptomatic Apical Periodontitis
Cavity (Dentin)
Previously treated with Periodontal Absess
Previously Treated (Inadiquate meriel root with Symp. Apical Periodontitis)
Pulpitis
Symptomatic Irreversible Pulpitis with Apical Periodontitis
Mild Periodontitis
Symptomatic Irreversible Pulpitis
Acute Pericoronitis
Generalized Attrition with Reversible Pulpitis
Acute Irreversbible Pulpitis
Comp. Hypersensitivity
Previously Initiated with Symptomatic Apical Periodontitis
Acute Irreversible Pulpitis
Broken Crown
Cold- Sensible Irreversible Pulpitis
Mild/Moderate Periodontitis
Impacted Canine
Necrosis with Symtomatic Apical Periodontitis
Food impaction
Previously Initiated Therapy
Previously Treated
Pulp Necrosis
Condensing Osteitis
Apical Abscess (Chronic)
Apical Abscess (Acute)
Asymptomatic Apical Periodontitis (Chronic)
Symptomatic Apical Periodontitis (Acute)
Dental checking
Previously Initiated
Acute Necrosis with Symp. Apical Periodontitis
Class 1 modification 1 (Tramatic bite)
Binax with Antarior Crowding
Horizontal Inspaction
Crown Commuting
Class I Cavity
TMJ dysfunction symdrome
Class II Cavity
Verticle Crown Fracture
Previously Done RCT
Open Heart Surgery--Ecospirin
Retained Bone Chips in Extracted Side
Multiple BDC
Previously initiated with Apical Abscess
Traumatic Ulcer
Detached FPD
Reversible Pulpitis
Irreversible Pulpitis with Apical Periodontitis
Cleaning of Teeth
Diastona b/w
Fixed PFD
Halitosis
Pulse: BP: Heart:
Calculus & Staining +++
BDC
RCT/Resto.
Initially Trreated
Roots are Seperated
Pits & Fissure Caries
Hypertension
Palpation : NAD
Pescium: NAD
Mobling/Tooth Mobility: No
NAD (No Abnormality Detected)
NAD (No Apparent Distress)
NAD (No Acute Disease)
NAD (No Appreciable Disease)
NAD/YES/NO
Visual Hygiene: Collagen/Colchgen
Palpation: NAD
Periodont: NAD
Malocclusion
Class I Cavity- Malocclusion
Proximal Cavity
new1
new2
Pulpitis with Pulp Caries
Generalized & Gum Hyperplasia
Partially Impacted
Necrosis with Alveolar Abscess
Kennedy Class III- Modification
Chronic Periodontitis
Sub-Gingival Calculus
BDR with Symp. Periodontitis
BDR with Acute Alveolar Abscess
Acute Alveolar Abscess
Class II Division I
Binax with Oral Thrush
Complete Denture: Upper/Lower
Partial Denture: Upper/Lower
Ext.: Extruction
Set...
Advice (I/X):
*
CBC
B/S (Random)
Bridge
BT Grouping
Crown
CT scan
ECG
ECHO
Ext.
Ext./RCT
FBS, 2HABF
Filling
FPD- Fixed Partial Denture
HbsAg
Kennedy
LCC: Light Cure Composite
None
Operculectomy
OPG
PD- Partial Denture
Periapical X-Ray
Pulpectomy
RBS
RCT
RCT followed by Crown
RCT with CAP
RCT with Post & Core Build up
RCT/Resto.
ReRCT
Resto.
RPD: Removable Partial Denture
RVG
S- Creature
S. Ext.
S. TSH
Scalling
Surgical Ext.
Urine
URINE R/E
USG of W/A
Widal Test
X-Ray Chest
X-Ray OPG
X-Ray PNS
X-Ray Submentovertex
Set...
T/X (Treatment Plan/to be done):
*
Arch Bar Warring on
Caries
Composite (LC) filling
Composite Buildup
Consultation
Corona Protection
Crown (E-max)
Crown (PFM)
Crown (Zirconia)
Crown Lengthening
Crown
Curettage
Extraction
FPD (Fixed Partial Denture)
G I filling
G.I. (LC) filling
Implant
Laser Filling
LCF
Midline Diastema (p/tooth)
PD- (Partial Denture)
Denture
S. Ext.
Resto
RCT
RCT/Resto
Tooth Preparation
Obstruction
RCT + Crown
PC Removed
Visit/Consultation Fees
Sealed
Build up & Crown cut
Impression taken
Crown cut
Re-RCT
PF: Permanent Filling
TF: Temporary Filling
Set...
Measurement 1:
*
Measurement 2:
*
Measurement 3:
*
Measurement 4:
*
R/X (Drug or Medicine advised):
*
Set...
Advised/Instructions:
*
Set...
Visit History
Notes/Pay Instruction (if any):
Data browse
Abrasion
Abscess on
Acute Pulpitis
Apthous ulcer
Attrition
BDR
Calculus+
Calculus++
Calculus+++
Caries on
Chronic Pulpitis
Cyst on
Discolouration of tooth
Erosion
Extrusion
Fracture Crown on
Fracture on
Gingival Hiperplasia
Gingivitis
G.C.- Gross Caries
Sensitivity
RCT: Root Canal Treatment ™
Tooth Missing
Gum Swelling Diseases
Swelling of interdental papilla
Irreversible Pulpitis
HTN
Pain
DM
Periodontitis
Necrosis with Acute Apical Abscess
Advanced periodontitis
BDR with Symp. Periodontitis
Necrosis followed by/due to trauma
Dislodgement of Crown
PD- Partial Denture
FPD- Fixed Partial Denture
Kennedy on
Normal Shedding
Symtomatic Apical Periodontitis
Irreversible Pulpitis with Symptomatic Apical Periodontitis
Cavity (Dentin)
Previously treated with Periodontal Absess
Previously Treated (Inadiquate meriel root with Symp. Apical Periodontitis)
Pulpitis
Symptomatic Irreversible Pulpitis with Apical Periodontitis
Mild Periodontitis
Symptomatic Irreversible Pulpitis
Acute Pericoronitis
Generalized Attrition with Reversible Pulpitis
Acute Irreversbible Pulpitis
Comp. Hypersensitivity
Previously Initiated with Symptomatic Apical Periodontitis
Acute Irreversible Pulpitis
Broken Crown
Cold- Sensible Irreversible Pulpitis
Mild/Moderate Periodontitis
Impacted Canine
Necrosis with Symtomatic Apical Periodontitis
Food impaction
Previously Initiated Therapy
Previously Treated
Pulp Necrosis
Condensing Osteitis
Apical Abscess (Chronic)
Apical Abscess (Acute)
Asymptomatic Apical Periodontitis (Chronic)
Symptomatic Apical Periodontitis (Acute)
Dental checking
Previously Initiated
Acute Necrosis with Symp. Apical Periodontitis
Class 1 modification 1 (Tramatic bite)
Binax with Antarior Crowding
Horizontal Inspaction
Crown Commuting
Class I Cavity
TMJ dysfunction symdrome
Class II Cavity
Verticle Crown Fracture
Previously Done RCT
Open Heart Surgery--Ecospirin
Retained Bone Chips in Extracted Side
Multiple BDC
Previously initiated with Apical Abscess
Traumatic Ulcer
Detached FPD
Reversible Pulpitis
Irreversible Pulpitis with Apical Periodontitis
Cleaning of Teeth
Diastona b/w
Fixed PFD
Halitosis
Pulse: BP: Heart:
Calculus & Staining +++
BDC
RCT/Resto.
Initially Trreated
Roots are Seperated
Pits & Fissure Caries
Hypertension
Palpation : NAD
Pescium: NAD
Mobling/Tooth Mobility: No
NAD (No Abnormality Detected)
NAD (No Apparent Distress)
NAD (No Acute Disease)
NAD (No Appreciable Disease)
NAD/YES/NO
Visual Hygiene: Collagen/Colchgen
Palpation: NAD
Periodont: NAD
Malocclusion
Class I Cavity- Malocclusion
Proximal Cavity
new1
new2
Pulpitis with Pulp Caries
Generalized & Gum Hyperplasia
Partially Impacted
Necrosis with Alveolar Abscess
Kennedy Class III- Modification
Chronic Periodontitis
Sub-Gingival Calculus
BDR with Symp. Periodontitis
BDR with Acute Alveolar Abscess
Acute Alveolar Abscess
Class II Division I
Binax with Oral Thrush
Complete Denture: Upper/Lower
Partial Denture: Upper/Lower
Ext.: Extruction
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