Dental Health 2020-21 Catalog

EXAMINATION RECORDS

EXAMINATION RECORD

Name

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

OCCLUSION:

PRIMARYMOLARRELATIONSHIP: LEFT:

FTP_________ MESIO __________ DISTO_________ FTP_________ MESIO __________ DISTO_________

Date

Tooth No.

Services Rendered

Charges

RIGHT:

PERMANENTMOLARRELATIONSHIP: LEFT:

CLI _________ CLII____________ CLIII__________ CLI _________ CLII____________ CLIII__________

RIGHT:

CUSPIDRELATIONSHIP: LEFT:

CLI _________ CLII____________ CLIII__________ CLI _________ CLII____________ CLIII__________

RIGHT:

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

INITIAL CONDITIONS

INITIAL CONDITIONS

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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

FORMS

32

31 30

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

32

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

31 30

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j

g h i

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a b c d e f

a b c d e f

s r q p o n m l

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s r q p o n m l

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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 RECORD

Name

Addresstosendstatementsto

Zip

Daytimephone

Birthdate

Name

ExaminationDate

Medical Alerts

AccountNumber

Tooth No.

Date

Servicerendered

Insurance

Charges Payments Balance

CLINICALDATA Generalcondition ofteeth Plaque

Stains

Abrasions

Conditionof presentrestorations Overhangs Conditionof the floorof mouth Palate: Hard Soft

Contactpoints

Cheeks

Lips

Frenum

Tongue

Ridges

Calculus: Slight

Moderate

Excessive

Oral cancerexam

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 ClinicalExam Vitality Test BloodPressure

Health Alerts

Totals

Back

DentalHealthProducts,Inc.•800-626-2163•Form#792-1057

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

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