AAPD Reference Manual 2022-2023
RESOURCES: RECORD TRANSFER
Record Transfer
To: __________________________________
Date: _________________________
__________________________________ __________________________________ Re: Patient: ___________________________________________ Nickname: _____________________ DOB: _________________ Gender: ____________ Parent/Legal guardian: ___________________________________________________________________ Special health care needs: No Yes ____________________________________________________ First encounter: ______________ Chief complaint: ______________________________________________ Last examination: _____________ Planned treatment: Completed Deferred Ongoing Oral hygiene: Excellent Good Fair Poor Non-existent Remarkable clinical findings: Radiographic history/date: Developmental anomalies Bitewings ________________________________ Soft tissue pathology Panoramic _______________________________ Fluorosis Full mouth _______________________________ Caries ( noncavitated cavitated) Single tooth ______________________________ Malocclusion Cephalogram _____________________________ Traumatic injury Other ___________________________________ Other (e.g., habits) __________________________ Comments _____________________________________________________________________________ ______________________________________________________________________________________ Professional preventive care: Management of developing occlusion: Fluoride (last treatment _____________) Monitored eruption/growth Sealants _________________________ Appliances __________________________________ Prescription fluoride/chlorhexidine Retention __________________________________ Dietary counseling Treatment completed __________________________ Comments _____________________________________________________________________________ ______________________________________________________________________________________ History of caries: None Minimal Moderate Severe Therapeutic/surgical interventions: Silver diamine fluoride Resin infiltration Pulp therapy Interim therapeutic restoration Other restoration ( resin amalgam crown __________) Extraction Other ________________________ Comments ______________________________________________________________________________ ______________________________________________________________________________________ History of trauma: No Yes (date:______________) Comments _______________________________ _______________________________________________________________________________________ Behavior: Cooperative Previous difficulties Ongoing considerations Adjunctive techniques: Nitrous oxide Sedation General anesthesia Other _______________ Referral for specialty care: No Yes _______________________________________________________ Additional considerations: ____________________________________________________________________ _______________________________________________________________________________________ Assessed caries risk: Low Moderate High Assessed periodontal risk: Low Moderate High Recall frequency: _________________________ Patient due for recall: ________________________ For additional information, please contact (_______) ___________________ __________________________________________ __________________________________________ Signature of person completing form Signature of attending dentist
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