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Name:- Age:-
Gender:- Sex:-
Address:-
Phone no:-
Surgery 1
Tooth extraction no :- X-ray picture:-
MOUTH OPENING
Mouth opening before surgery:-
Mouth opening on 2
nd
day(in mm):-
Mouth opening on 7
th
day(in mm):-
FACIAL SWELLING (2
nd
day)
a)The distance (mm) between the lateral corner of the eye and the angle of
the mandible._______
b) The distance (mm) between the tragus and the outer corner of the
mouth._______
c) The distance (mm) between the tragus and the soft tissue pogonion.______
FACIAL SWELLING (7
nd
day)
a)The distance (mm) between the lateral corner of the eye and the angle of
the mandible._______
b) The distance (mm) between the tragus and the outer corner of the
mouth._______
c) The distance (mm) between the tragus and the soft tissue pogonion.______
Difference between the swelling on 2
nd
post-operative day and
7
th
postoperative day (in mm):________.
VAS SCALE
0 hrs:-
30 min:-
1 hr:-
12hr:-
24hr:-
48hr:-
Time of first perception of pain:-________(hh:mm)
Duration of surgery after anesthetic administration:- ________
Efficacy of piroxicam (Likert scale):-
Excellent Very Good Good Fair Poor
Rescue medication if required:-
Time :-_______ Amount:-_______
Any adverse reactions noted:-
-Notes-
Surgery 2
Tooth extraction no :-
MOUTH OPENING
Mouth opening before surgery:-
Mouth opening on 2
nd
day(in mm):-
Mouth opening on 7
th
day(in mm):-
FACIAL SWELLING (2
nd
day)
a)The distance (mm) between the lateral corner of the eye and the angle of
the mandible._______
b) The distance (mm) between the tragus and the outer corner of the
mouth._______
c) The distance (mm) between the tragus and the soft tissue pogonion.______
FACIAL SWELLING (7
nd
day)
a)The distance (mm) between the lateral corner of the eye and the angle of
the mandible._______
b) The distance (mm) between the tragus and the outer corner of the
mouth._______
c) The distance (mm) between the tragus and the soft tissue pogonion.____
Difference between the swelling on 2
nd
post-operative day and
7
th
postoperative day (in mm):________.
VAS SCALE
0 hrs:-
30 min:-
1 hr:-
12hr:-
24hr:-
48hr:-
Time of first perception of pain:-________(hh:mm)
Duration of surgery after anesthetic administration:- ________
Efficacy of piroxicam (Likert scale):-
Excellent Very Good Good Fair Poor
Rescue medication if required:-
Time :-_______ Amount:-_______
Any adverse reactions noted:-
-Notes-