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Dental Chart

This document contains a dental patient record form from the University of the Philippines Dental Clinic. The form collects information about the patient's dental and medical history. It includes sections to document the intraoral examination, existing dental conditions, treatment done, and other clinical findings. It also contains a patient information record to collect the patient's name, dental history, medical history, current medications, allergies, and other relevant medical information.

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Doom Refuge
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3K views

Dental Chart

This document contains a dental patient record form from the University of the Philippines Dental Clinic. The form collects information about the patient's dental and medical history. It includes sections to document the intraoral examination, existing dental conditions, treatment done, and other clinical findings. It also contains a patient information record to collect the patient's name, dental history, medical history, current medications, allergies, and other relevant medical information.

Uploaded by

Doom Refuge
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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UNIVERSITY HEALTH SERVICE

UNIVERSITY OF THE PHILIPPINES Student /OPD Number: __________________


DILIMAN, QUEZON CITY Student Retired
Faculty Dependent
ALLERGIC TO _________________________________________________________________________ Employee Outsider

DENTAL CLINIC
OUT PATIENT RECORD
LASTNAME______________________________________________________________ Date of Birth ______________________________Age ________Sex _______
FIRSTNAME_____________________________________________________________ Contact No:____________________Religion ________Civil Status_______
MIDDLENAME___________________________________________________________ School/College/Office/Department_______________________________
PresentAddress __________________________________________________________________________________________________________________________________
PARENT/GUARDIAN___________________________________________________ RELATIONSHIP_________________OCCUPATION_____________________
PERMANENT ADDRESS ________________________________________________________________________ CONTACT NO ______________________________________

INTRAORAL EXAMINATION
STATUS LEFT
RIGHT
55 54 53 52 51 61 62 63 64 65

TEMPORARY TEETH

TREATMENT DONE
P
E
EXISTING CONDITION
R
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 M
A
3 N
E
N
T

T
E
E
T
H

48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
____________________________________
TEMPORARY TEETH
3

STATUS LEFT
RIGHT

85 84 83 82 81 71 72 73 74 75

LEGEND:
C –Caries JC – Jacket Crown (P-Porcelain, M-Metal, G-Gold, A-Acrylic, C-Ceramic) X – Extraction due to Caries
Am – Amalgam Filling Co – Composite Sp – Supermumerary
G – Goldfilling In – Inlay/On- Inlay (G: Gold; M: Metal; C: Ceramic)
Im – Impacted Tooth Frac – Fractured (Co, AM, Tooth)
PFS – Pit & Fissure Sealant TF – Temporary Filling

Gingivitis Periodontal Condition Occlusion Appliances


Mild Localized Class 1 Orthodontic
Moderate Generalized Class 2 Stayplate
Severe Chronic Class 3 RPD
Acute Midline Deviation Upper Lower
Facial Dental Complete
Crowding Upper Lower
TMD

Other Clinical Findings


__________________________________________
__________________________________________ __________________________
Dentist / Date
PATIENT INFORMATION RECORD
Name: _____________________________________________________________________________________________________________
Last First Middle

DENTAL HISTORY
Previous Dentist: __________________________
Last Dentist visit: __________________________

MEDICAL HISTORY
Name of Physician: Dr. ______________________________Specialty, if applicable: _______________
Office Address: ____________________________________ Office Number: _____________________

1. Are you in good health? Yes No


2. Are you under medical treatment now? Yes No
If so, what is the condition being treated? _________________________
3. Have you ever had serious illness or surgical operation? Yes No
If so, what illness or operation? _________________________________
4. Have you ever been hospitalized? Yes No
If so, when and why? __________________________________________
5. Are you taking any prescription/non-prescription medication? Yes No
If so, please specify ___________________________________________
6.Do you use tobacco products? Yes No
7. Do you use alcohol, cocaine or other dangerous drugs? Yes No
8.Are you allergic to any of the following: Yes No
( ) Local Anesthetic (ex. Lidocaine) ( ) Penicillin, Antibiotics
( ) Sulfa drugs ( ) Aspirin ( ) Latex ( ) Other ___________________
9.Bleeding Time _____________________
10. For women only: Are you Pregnant? Yes No
Are you nursing?
Are you taking birth control pills?
11. Blood Type _______________
12. Blood Pressure ________________________
13. Do you have or have you had any of the following? Check which apply Yes No

( ) High Blood Pressure ( ) Heart Disease ( ) Cancer / Tumors


( ) Low Blood Pressure ( ) Heart Murmur ( ) Anemia
( ) Epilepsy / Convulsions ( ) Hepatitis / Liver Disease ( ) Angina
( ) AIDS or HIV Infection ( ) Rheumatic Fever ( ) Asthma
( ) Sexually Transmitted disease ( ) Hay Fever / Allergies ( ) Emphysema
( ) Stomach Troubles / Ulcers ( ) Respiratory Problems ( ) Bleeding Problems
( ) Fainting Seizure ( ) Hepatitis / Jaundice ( ) Blood Diseases
( ) Rapid Weight Loss ( ) Tuberculosis ( ) Head injuries
( ) Radiation Therapy ( ) Swollen ankles ( ) Arthritis / Rheumatism
( ) Joint Replacement / Implant ( ) Kidney disease ( ) Others
( ) Heart Surgery ( ) Diabetes
( ) Heart Attack ( ) Chest pain
( ) Thyroid Problem ( ) Stroke

____________________________
Signature / Date

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