Date :...........................................................................

Student :...........................................................................
Foto Pasien

3x4
Supervisor :...........................................................................
berwarna
Signature/ Approval :...........................................................................

PATIENT IDENTITY/ Identitas Pasien

1. CHILD’S FULL NAME/ Nama Lengkap Anak :
___________________________________________________________________
2. GENDER/ Jenis Kelamin : BOYS/ Laki-laki
GIRLS/ Perempuan
3. AGE/ Usia :
___________________________________________________________________
4. SCHOOL LEVEL/ Kelas :
___________________________________________________________________
5. DATE OF BIRTH/ Tanggal Lahir :
___________________________________________________________________
6. PARENT’S NAME/ Nama Orang Tua :
___________________________________________________________________
7. ADDRESS/Alamat :
___________________________________________________________________
8. TELEPHONE/ Telepon :
___________________________________________________________________
9. OCCUPATION/ Pekerjaan :
___________________________________________________________________
10. CHILD’S PHYCISIAN/PEDIATRICIAN/ Dokter/ Dokter Anak :
___________________________________________________________________
11. ADDRESS/ Alamat :
___________________________________________________________________
12. TELEPHONE/ Telepon :
___________________________________________________________________
13. ANAMNESIS/Chief Complaint(s)/ Keluhan Utama :
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
MEDICAL AND DENTAL HISTORY/ Riwayat Kesehatan Umum Dan Gigi

1. Any problem with physical growth/Apakah ada gangguan pertumbuhan fisik ?

Yes ( ) No ( )
2. Any history of congenital heart disease/ Apakah ada riwayat jantung bawaan ?
Yes ( ) No ( )
3. Dose your child bruise easily or bleed for a prolonged period of after being cut/
Apakah anak saudara mudah berdarah atau lama waktu pendarahan ketika luka ?
Yes ( ) No ( )
4. Any history of anemia/ Apakah pernah menderita anemia ?
Yes ( ) No ( )
5. Any history of hepatitis or jaundice/ Apakah anak pernah menderita hepatitis ?
Yes ( ) No ( )
6. Is your child’s allergic to any medication/ Apakah punya allergi obat ?
Yes ( ) No ( )
7. Is your child currently taking any medicine/ Apakah saat ini minum obat ?
Yes ( ) No ( )
If yes, medication _________________________________________________
8. Has your child been hospitalized/Apakah anak saudara pernah masuk Rumah Sakit?
Yes ( ) No ( )
Reason : _________________________________________________________
9. Does your child have a tooth ache/ Apakah sedang sakit gigi ?
Yes ( ) No ( )
10. Has your child ever had a tooth ache/ Pernahkah anak saudara sakit gigi ?
Yes ( ) No ( )
11. It this your child first dental visit/Apakah ini merupakan kunjungan pertama ke dokter
gigi?
Yes ( ) No ( )
12. Has your child ever had an unfavorable dental experience/
Apakah anak saudara punya pengalaman yang kurang menyenangkan dengan
dokter gigi?
Yes ( ) No ( )
If yes, when/ Bila ya, kapan ____________, where/ dimana ________________;
Reason(s)/ mengapa ________________________________________________
13. Does/has your child having oral/ sucking habit beyond 1 year of age/ Apakah punya
kebiasaan buruk setelah usia 1 tahun?
Finger sucking ( ) Lip biting ( ) Tongue thrust ( )
14. Does or has your child have or had difficulty openings his/her jaw/ Apakah anak anda
sedang/ pernah mengalami kesulitan membuka mulut ?
Yes ( ) No ( )
15. Does or has your child have or had popping or cliking noise or pain during eating or
yawning/ Apakah pada saat membuka mulut terasa sakit atau terdengar suara click,
popping pada sendi rahangnya ?
Yes ( ) No ( )
16. How ofter does your child brush/ Berapa kali menyikat gigi ? _______times/kali
Yes ( ) No ( )
17. Does your child use a fluoride pasta/Apakah menggunakan pasta mengandungfluor?
Yes ( ) No ( )
18. Has your child ever had fluoride treatment/ Pernahkah diberikan fluor ?
Yes ( ) No ( )
PATIENT BEHAVIOUR RATINGS/ Peringkat Perilaku Pasien
Rating Before treatment/ During treatment/
Frankl scale
No Sebelum perawatan Selama perawatan
1. Definitely negative, refusal of
treatment, crying forcefully, fearful,
extreme negativisim/ Sangat
negative, penolakan perawatan,
menangis meronta-ronta,
ketakutan, negative ekstrim.
2. Negative, reluctant, uncooperative,
limited negativism, withdrawn/
Negatif, keberatan, tidak
kooperatif, negative terbatas.
3. Positive, accept treatment but may
be cautious or reserve, follows
directions/ Positif, menerima
perawatan dengan waspada,
mengikuti instruksi
4. Definitely positive, good rapport,
interested in dental procedure,
laugh and enjoy/ Sangat positif,
hubungan yang simpatik, tertarik
dengan prosedur dental.

PLAQUE SCORE/ NILAI PLAK

18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
55 54 53 52 51 61 62 63 64 65
Buccal
Palatal
Lingual
Buccal
85 84 83 82 81 71 72 73 74 75
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38

Score/ Nilai :
EXTRA ORAL EXAMINATION/ PEMERIKSAAN EKSTRA ORAL
1. Facial form / Bentuk wajah
o Bilateral symmetry/ Simetri BilateraL
o Asymmetry/ Asimetri
2. Profile/ Profil :
o Straight/ Lurus
o Convex/ Cembung
o Concave/ Cekung
3. Lips seall/ Katup bibir
o Positive
o Negative
4. TMJ
a. Cliking/ Bunyi klik :
o Yes
o Right/kanan
o Left/ kiri
o No
b. Pain/ Nyeri
o Yes
o Right/kanan
o Left/ kiri
o No
c. Oklusi :
o Good :
_____________________________________________
o Poor :
_____________________________________________
o Klasifikasi :
_____________________________________________
d. Gerakan Mandibula/ ROM :
- Buka Tutup : * Normal : ____________mm
* Trismus : ____________mm
* Deviasi : - Right/ Kanan : ____________mm
- Left/ Kiri : ____________mm
* Defleksi : - Right/ Kanan : ____________mm
- Left/ Kiri : ____________mm
- Lateral : * Normal : ____________ Hambatan : _________
* Simetris : ____________
* Non Simetris : - Kanan _______mm
- Kiri _________mm
5. Body posture/ postur tubuh :
o Straight/ tegap
o Kiphosis/ kifosis
o Scoliosis/ skoliosis
o Lordosis/ lordosis
INTRA ORAL EXAMINATION
o Stage of dentition/ tahapan geligi :
o Primary/ sulung Mixed/campuran
o early/ awal
o Late/lanjut
o Permanent/tetap

o Soft tissue status/ status jaringan lunak :

a. Gingivitis : region ________________________
b. Stomatitis : region ________________________
c. Gum boil/ fistulae : region ________________________

o Dentofacial anomaly/ anomaly gigi :

o Yes
o No

o Malocclusion/ Maloklusi
o Yes,
o Molar Angle Classification
 Right/ Kanan : ________________________
 Left/ Kiri : ________________________
o Canine Angle Classification
 Right/ Kanan : ________________________
 Left/ Kiri : ________________________
o No

o Garis Median/ Median line

o Appropriate (sesuai)
o No (tidak),
 Maxilla shifting (RA bergeser : __________mm
 Mandibula shifting (RB bergeser : __________mm

o Premature loss/ gigi tanggal dini :

__________________________________________________

o Over retained primary tooth/ persistensi gigi sulung :

__________________________________________________
VII. ODONTOGRAM/ odontogram

Patient’s name : .....................................................................................

Age : .....................................................................................

TOOTH ICDAS ANNOTATION ANNOTATION ICDAS TOOTH

11 (51) 21 (61)
12 (52) 22 (62)
13 (53) 23 (63)
14 (54) 24 (64)
15 (55) 25 (65)
16 26
17 27
18 28

TOOTH ICDAS ANNOTATION ANNOTATION ICDAS TOOTH

48 38
47 37
46 36
45 (85) 35 (75)
44 (84) 34 (74)
43 (83) 33 (73)
42 (82) 32 (72)
41 (81) 31 (71)

Diperiksa pada tanggal :

Nama Operator :
Nama Supervisor :
Tanda Tangan Supervisor :
Annotation:
ORAL FINDING DIAGNOSIS/ TREATMENT PLAN
Tooth Diagnosis Treatment Plan

Diperiksa pada tanggal :

Nama Operator :
Nama Supervisor :
Tanda Tangan Supervisor :
TREATMENT
Date & Supervisor
Treatment
Time Signature