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    PHD Case History

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    Som Nath
    This document contains a dental patient history form with sections for patient identification details, chief complaint, medical history, dental history, family history, personal history, general examination, local examination, provisional diagnosis, investigations, diagnosis, and treatment plan. It collects information over multiple visits to assess and treat a patient's dental condition.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    PHD Case History

    Uploaded by

    Som Nath
    70 views9 pages
    This document contains a dental patient history form with sections for patient identification details, chief complaint, medical history, dental history, family history, personal history, general examination, local examination, provisional diagnosis, investigations, diagnosis, and treatment plan. It collects information over multiple visits to assess and treat a patient's dental condition.

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    © © All Rights Reserved

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    PDF, TXT or read online from Scribd

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    This document contains a dental patient history form with sections for patient identification details, chief complaint, medical history, dental history, family history, personal history, general examination, local examination, provisional diagnosis, investigations, diagnosis, and treatment plan. It collects information over multiple visits to assess and treat a patient's dental condition.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    70 views9 pages

    PHD Case History

    Uploaded by

    Som Nath
    This document contains a dental patient history form with sections for patient identification details, chief complaint, medical history, dental history, family history, personal history, general examination, local examination, provisional diagnosis, investigations, diagnosis, and treatment plan. It collects information over multiple visits to assess and treat a patient's dental condition.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 9

    DEPARTMENT OF PUBLIC HEALTH HOSPITAL &R

    TRIVENI
    DENTISTRY
    INSTITUTE OF SCIENCES,
    RESEARCH CENTRE,DENTAL
    BILASPUR, CHHATTISGAR

    Student's Name:
    Date
    OPNO.
    Patient's Name
    Age
    Sex:
    Date and place of Birth
    Education Occupation:
    Total income of
    family
    No. of family
    members
    Percapita income per month
    Address

    Contact No.

    Chief complaint

    I. History of present illness:

    Medical History
    V Dental History

    P A R

    N. Family History
    a. Siblings
    Number Age
    Has any
    family member suffered from a similar problem ?
    Do you
    know any illnesses that run in your family?
    b. Marital Status Married Unmarried
    C. Children (if any) Number
    VI. Age
    Personal History
    /a. Personal Habits:

    Type Number Frequency Duration


    1. Smokingg
    2. Smokeless tobacco

    (with/without pan chewing)


    3. Pan Chewing

    G (with/without tobacco)
    4. Alcoholism
    b.
    OK Habits related to oral
    Mouth Thumb
    cavity:
    Tongue Bruxism
    Breathing Sucking Thrusting Lip/nail/Pencil/Bitting

    Frequency:
    Duration
    c) Oral Hygiene Practices:
    1.Type of cleaning:
    Specify if any other)Toothbrush Finger
    Finger Twi
    Twigg Others
    2.Method of Cleaning:
    3.Material used: Vertical Horizontal Circular
    Toothpaste Tooth powder
    Sand Charcoal
    4.Frequency of Brick powder Any other U
    cleaning: Once Twice
    S.Time of brushing: Before
    meals
    Twice Thrice
    6. After meals
    Frequency of changing the toothbrush;
    7.Use of other oral
    hygiene aids: FlossingInterdentalaids
    Oral Mouth rinse Others
    d) Dietary habits:
    1. Source of water: Bore Well Others
    2.Vegetarian Mixed
    3. Dietary chart:

    Staple Diet:
    Time Item Sugar Exposure
    456

    Sugar consumption (per day)


    Type of Carbohydrate:
    Frequency: Once Twice Thrice Fourtimes
    Please specify if more:

    Time of intake: With meals In-between meals


    Form and consistency Solid Liquid
    Sticky Non stick
    VIL
    General Examination:
    a) Gait
    b)
    Posture
    Built:

    VIll. Local Examination:


    a)
    Extra Oral:
    1.
    Symmetry:
    2 Profle:

    3. T.MJ.:
    Lymph nodes
    5. Lips
    b) Intra Oral:

    1. Soft Tissue
    Labial mucosa:

    Bucca Mucosa

    Palate
    Tongue
    Floor of mouth

    Alveolar mucosa:
    Gingiva:
    2 Hard tissue:

    Type of dentition:Deciduous MixedPermanent


    Teethpresent

    Teeth absent and reason for loss:

    Dental caries:

    Non Cavitated:

    Cavitated

    Cavitated with pulp exposure:

    Root stumps:

    Filledteeth:

    Any prosthesis: Crown

    Bridge

    RPD/Implant
    Wasting disease a. Generalized b. Localized (mention tooth)
    Attrition
    B. Abrasion
    Erosion

    chamelhypoplasia: Generalised Localised


    Dental Fluorosis Yes No
    Supernumerary teeth:
    Malocclusion:
    Fractured/Non vital tooth:
    Stains
    Extrinsic Intrinsic
    Any other
    anomaly please specify:
    Periodontal Status
    Gunginitis:
    Generalised Localised (mention
    tooth)
    Gingival recession:
    Periodontal pocket:
    Mobility of teeth:
    A. Oral Hygiene Status

    Dental deposit:

    Plaque Stains Calculus


    Good Fair
    Poor
    INDEX
    IX. Provisional diagnosis:

    Investigation:

    XI Diagnosis:
    Xll. TreatmentPlan:

    PATIENT SIGNATURE
    XIll. Workdone:

    Date Work done Remarks

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