Department: Patient History I

Oral Medicine, Periodontology, Diagnosis & Radiology
Department
Patient history
I. Patient identification:
Name: ………………………. Age: …… Gender: …..............

Code number: …. Date of examination: …………………………….
Date of birth: …………….. Birth place: ………… ……….……….
Address: ……………… Phone number: ……………………………..
Occupation: ……………. Marital status: ……………………………
Physician name: ………… Address: …………………………………
II .Chief complaint:
…………………………………………………………………………
…………………………………………………………………………
…………………………………………………………………………
…………………………………………………………………………
…………………………………………………………………………
…………………………………………………………………………
III. History chief complaint:
Onset: .............………….……………... Date:

........……............................
Duration: ……...…………………………………………………………...
Course: …….…………. ………………………………..............................
Character & Severity:
…….………………………………………………..
Precipitation factor: ……….……………………………………………....
Relation to other activity: ……….…………………………………….......
Location and site: ……………….………………………………………...
Reliving factor: ………………….…………………………………….......
Associated phenomenon: ………….…………………………………........
Previous medication: ……………..…………………………………….....
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IV. Medical history:
Are you in a good health?

Are you under the care of physician?
Did you have any operations?
Do you have any series illness?
Do you have any of these problems?
Rheumatic heart disease Heart surgery
Congenital heart disease hypertension
Coronary heart disease (angina, coronary occlusion)
Hepatitis (A, B, C), Jaundice or Liver disease
AIDS T.B Peptic ulcer arthritis
Venereal disease allergy renal disease low blood pressure
Do you have thyroid problems?
Do you have any blood disorder, blood transfusion?
Have you had any surgery or radiotherapy for a tumor or other lesion in
the head and neck?
Do you take any medication?
Do you take any of these drugs?
Antibiotics or sulpha anticoagulant
Cortisone Aspirin
Nitroglycerine Antihypertensive drugs
Digitalis
Do you have allergy against any drug?
Women Only:
Are you pregnant? Expect delivery date .........................................

Do you have any problems associated with the menstrual period?
Date of the last menstrual cycle: ..................................................................
Are you taking contraceptive drugs?
V. Family history:
......................................................................................................................
......................................................................................................................
......................................................................................................................
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VI .Social history:
......................................................................................................................
......................................................................................................................
......................................................................................................................
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VII. Past dental history:
Frequency of dental prophylaxis..................................................................

Date of last examination...............................................................................
Periodontal therapy: .....................................................................................
Do you brush your teeth? ………………………….........
Do you have bleeding after brushing? ...............................
Do you have any abnormal sensation in your gum?
Pain Numbness Itching Other
Reaction to local anaethesia:
...................................................................................................................
History of extraction & any complications
......................................................................................................................
......................................................................................................................
Endodontic treatment: .............................. Date: ..…............
Fixed Prosthesis/site: ............................... Date: …………..
Removable Prosthesis/type: ……………….. Date: ……...……
Dental appliance construction: ....................................................................
Oral Surgical Procedures: ............................................................................
Surgical procedure about the mouth: ...........................................................
Past orthodontic treatment: ..........................................................................
Others:
……………………………………………………………………………
…………………………….....……………………………………………
…………………………………………………………………………….
VIII. Personal habits :

Oral hygiene: ...............................................................................................
Habits harmful to oral cavity:

Smoking Cheek biting Mouth breathing
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Bruxim Clenching Thumb sucking
Alcoholism Dietary history Other
II Physical examination
A. General physical appraisal:

…………………………………………………………………
………………...……………………………………………….
B. Vital sign:
Blood pressure Pulse rate

Respiratory rate Temperature
C. Extra oral examination (Normal/Abnormal):
Skull ………………………………………………..
Face …………………………………………………
Eyes …………………………………………………
Nose ………………………………………………....
Skin ……………………………………………….…
Hair ……………………………………………….…
Neck ………………………………………………....
Lymph nodes ………………………………………..
T.M.J ………………………………………………..
….…………………………………………………………………………
…………………………………………………………………………….
In Case of Abnormality:
* Ulcer * Swelling * White/Red lesion * Pigmented Lesion * Else
Duration & Location: …..…………………………………………………

Site: ………………………………………………………………………
Color : …………………………………………………………………….
Consistency: ………………………………………………………………
Borders: …………………………………………………………………...
Patient’s Reaction to Palpation: Painful / Tenderness
Results of draining lymph nodes examination: …..……………………….
Others: …………………………………………………………………….
….………………………………………………………………………….
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.
D. Intra oral examination :
1. Soft tissues
Lip ……………………………………………...
Cheek …………………………………………...
Tongue ………………………………………….
Floor of the mouth ……………………………...
Oropharynx ……………………………………..
Soft palate ………………………………………
Hard palate ………………………………………
In Case of Abnormality:
* Ulcer * Swelling * White/Red lesion * Pigmented Lesion * Else
Duration & Location: …..…………………………………………………

Site: ……………………….………………………………………………
Color : …………………………………………………………………….
Consistency: ………………………………………………………………
Borders: …………………………………………………………………...
Patient’s Reaction to Palpation: Painful / Tenderness
Results of draining lymph nodes examination: …..……………………….
Others: …………………………………………………………………….
….………………………………………………………………………….
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2. Teeth:
Number (Missing) …..….…………………………………………………...
Contact relation …..……...……….…. Contour ………………………….
Caries ………………..……… Color & stains …...…….……...……..
Form ………..……………………………………………....…..…………
Structure …….....…………………………………………....……………..
Fracture ……….………………………………………….…………....…
Impaction ……….………………………………….……………………..
Restoration …………………………….………………..…………..…….
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….………………………………………………………………………….
3. Periodontium
Gingiva:
Color: ..………………………………….………………………………
Form:
Interdental papilla: ……………………………………….………………..
Gingival margin: …………………………………………………………..
Contour: …………………………………………………………..……….
Width of attached gingival: ………………………………….……………
Consistency: ………………………………………………………………
Surface texture: …………………………………………………………...
Bleeding: …………………………….……………………………………
Recession …………………………………….............................................
Cleft: …………………………………………………………………..…..
Fernum attachment: ……………………….................................................
Gingival index:
Plaque index:
Probing depth:
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Loss of attechment:
Furcation envolvement
……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
Mobility
……………………………………………………………………………
……………………………………………………………………………
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III Adjunctive diagnostic information

A. Radiographilic examination:
……………………………………………………………………………
……………………………………………………………………………
B. Laboratory Investigations:
……………………………………………………………………………
……………………………………………………………………………
C. Microscopic examination of biopsy
……………………………………………………………………………
……………………………………………………………………………
IV.Diagnosis
……………………………………………………………………………
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D. Referrals & Consultation
………………………………...…………………………………………
VI .Treatment plan
……………………………………………………………………………
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Signature: ………………………………… Date: ……………………

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Oral Medicine, Periodontology, Diagnosis & Radiology

Name: ………………………. Age: …… Gender: …..............

III. History chief complaint:

Onset: .............………….……………... Date:

Are you in a good health?

Are you pregnant? Expect delivery date .........................................

VII. Past dental history:

Frequency of dental prophylaxis..................................................................

VIII. Personal habits :

Habits harmful to oral cavity:

A. General physical appraisal:

Blood pressure Pulse rate

C. Extra oral examination (Normal/Abnormal):

Duration & Location: …..…………………………………………………

Duration & Location: …..…………………………………………………

III Adjunctive diagnostic information

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