Dental Health 2019 Catalog

EXAMINATION RECORDS

EXAMINATION RECORD

Name

NAME__________________________________________ BIRTHDATE_____________________________ ADDRESS_______________________________________________________________________________ HOMEPHONE _____________________________WORKPHONE__________________________________ PHYSICIAN’SNAME&PHONENUMBER_______________________________________________________ MEDICALALERT: _______________________________________________________________________________________ Conditionof thefloorofmouth ______________________________________________________________ Palate:Hard _____________ Soft _____________Cheeks _________________Lips_________________ Frenum _____________________Tongue ______________________ Ridges _______________________ TMJ ________________________Neck ________________________ OralCancerExam_______________

OCCLUSION:

PRIMARYMOLARRELATIONSHIP: LEFT:

FTP_________ MESIO __________ FTP_________ MESIO __________

DISTO_________ DISTO_________

Date

Tooth No.

Services Rendered

Charges

RIGHT:

PERMANENTMOLARRELATIONSHIP: LEFT:

CL I _________ CL I I ____________ CL I _________ CL I I ____________

CL III__________ CL III__________

RIGHT:

CUSPIDRELATIONSHIP: LEFT:

CL I _________ CL I I ____________ CL I _________ CL I I ____________

CL III__________ CL III__________

RIGHT:

FORMS

OVERJET: OVERBITE: _______ %MIDLINE:CROSSBITE _______________ OPENBITE:______________________________________________________________________________ HABITS ________________________________________________________________________________ ________ MM

INITIAL CONDITIONS

INITIAL CONDITIONS

1 2

3

4 5 6 7 8 9 10 11 12 13 14 15 16

1 2

3

4 5 6 7 8 9 10 11 12 13 14 15 16

32

31 30

29 28 27 26 25 24 23 22 21 20 19 18 17

32

31 30

29 28 27 26 25 24 23 22 21 20 19 18 17

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FORM#1810

Front

Back

Examination Record (Initial vs Current) Form 8-½" x 11" form, printed on 80# white paper with black ink. Shrink wrapped in 100 sheets per package. 792-1810 Each .................................... $15.25

EXAMINATION RECORDS (CLINICAL DATA)

EXAMINATION RECORD

Name

Address to send statements to

Zip

Daytimephone

Birthdate

Name

Examination Date

Medical Alerts

Account Number

Tooth No.

Date

Service rendered

Insurance

Charges Payments Balance

CLINICAL DATA General condition of teeth Plaque

Stains

Abrasions

Condition of present restorations Overhangs Condition of the floor of mouth Palate: Hard Soft

Contact points

Cheeks

Lips

Frenum

Tongue

Ridges

Calculus: Slight

Moderate Excessive Oral cancer exam

TMJ

Neck

Occlusion

Tooth

Services necessary

Fees

1 2 3 4 5 6 7 8 9

10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32

X-rays Date Diagnostic Models Date Photograph Clinical Exam Vitality Test Blood Pressure

Health Alerts

Totals

Back

%FOUBM)FBMUI1SPEVDUT *OD r

r'PSN

1057

Front

Examination Record (Clinical Data) Form 8-½" x 11" form, printed on 80# white paper with black ink. Shrink wrapped in 100 sheets per package. 792-1057 Each .................................... $15.25

767

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