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Long Case Format Final Yogita

The document is a comprehensive medical and dental examination form that collects patient information, including personal, medical, and dental history, as well as details on oral hygiene and dietary habits. It includes sections for general, extraoral, and intraoral examinations, along with periodontal status and provisional diagnosis. Additionally, it outlines treatment plans and requires informed consent from the patient for the examination and procedures.

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monagalaxya34
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© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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53 views8 pages

Long Case Format Final Yogita

The document is a comprehensive medical and dental examination form that collects patient information, including personal, medical, and dental history, as well as details on oral hygiene and dietary habits. It includes sections for general, extraoral, and intraoral examinations, along with periodontal status and provisional diagnosis. Additionally, it outlines treatment plans and requires informed consent from the patient for the examination and procedures.

Uploaded by

monagalaxya34
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Name: O.P.

D NO:

Age: Date:

Sex: Phone No:

Occupation: Address:

Chief Complaint:

History of present illness:

Past Dental History:

Medical History:

Family History:

Personal History:

Adverse Habit

Pan chewing:

Smoking:

Alcohol:

Bruxism:

Others:
Oral Hygiene Habits:
Type Of Brush:
Dentifrice:
Frequency:
Technique:
Others:

Dietary Habits:

General Examination:
1) Gait:
2) Posture:
3) Build:
4) Others:

Extraoral Examination:
Symmetry of Face:
Profile:
Lymph Glands:
TMJ:
Lip Seal:

Intraoral Examination:
Buccal Mucosa:
Labial Mucosa:
Tongue:
Floor of the Mouth:
Hard Palate:
Soft Palate:
Oral Hygiene Status:

a) O.H.I.S (Green & Vermillion)

Debris Index: Calculus Index:

6 1 6 6 1 6

Total D.I. Score: Total C.I. Score:

Total O.H.I.S. Score =

b) Status of Oral Hygiene:

c) Halitosis:

Gingival Status:

Color:

Consistency:

Contour:
Size:

Position:

Surface texture:

Bleeding on Probing:

Stillman`s Cleft:

Mcall`s Festoon:

Exudation:

Abscess:

Extrusion/Drifting:

Food impaction:

Plunger cusp:

Muco-gingival Problems:

Recession:

Tension test:
Width of Attached Gingiva:
Depth of Vestibule:
Frenal Attachment:
Teeth Missing:

Periodontal Status:

Furcation
Mobility
Width of
attached
gingiva
Clinical
attachment
loss
Recession
Probing
depth
8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8
Pocket depth

Recession
Clinical
Attachment
loss
Width of
attached
gingiva

Mobility
Furcation

Carious:
Root piece:
Over filling:
Hypersensitivity:
Wasting Disease:
- Attrision/Abrasion/Erosion
Occlusal wear:
Occlusal Analysis:
Type of occlusion-
Overjet-
Crossbite-
Open contacts-
Fremitus test:
Pathologic tooth migration:

PROVISIONAL DIAGNOSIS:

INVESTIGATIONS:

A) Radiological

i) IOPA X-ray:

ii)OPG:

B) Laboratory Investigation:

RBC count: WBC count: Platelet count:

Differential count: Other:

HB: BT: CT:

DIAGNOSIS:
PROGNOSIS: Overall-

Individual-

TREATMENT PLAN:

Preliminary Phase:

1) T/t of emergencies

2) Extraction

Phase 1 Therapy (non-surgical phase):

Phase 2 Therapy (Surgical Phase):

Phase 3 Therapy (Restorative phase):

Phase 4 Therapy (Maintenance phase):


DEPARTMENT OF PERIODONTICS AND IMPLANTOLOGY

Date:

Informed Consent

I _________ ______________________________ hereby give my consent to


the clinical examination being performed on me. The nature of examination
and the risk involved in the procedure is being explained to me in a language
known to me. I hereby voluntarily give my consent without any fear or
pressure to participate in this study.

Signature/Thumb impression of the patient

संमतीपत्र:

दिन ंक- .

मी ख ली सही करण र (संपूणणन ंव)________________________________ य संमतीपत्र्द्व रे

म झ्य वर, डॉक्टर व त् ंचे सहक री य ंच्य कडून व त् ंच्य म र्णत िं तश्ल् यदचदकत्स करून

घेऊन त् अनुषंग ने त् ंन आवश्यक व टण री िं तशसत्रदिय व शुश्रुष , औषधे, भूल िे णे

य तील कोणतीही दिय करण्य स संपूणण संमती, स्वखुशीने िे त आहे . सिरची शस्त्रदिय

/िं न्तोपच र पद्धतीवगेरे कश प्रक रची असेल व त् चे क य परीण म होऊ शकतील, ते मल

समज वून स ंदगतले आहे व ते मल म दहत आहे .

पेशंटची सही

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