Taibah University

College of Dentistry
Department of Pediatric Dentistry

PATIENT ASSESSMENT CHART

Students Name: . Students ID
__________________________________________________________________________

PERSONAL HISTORY
Pt Name: . Gender:
Age: .. Date of Birth:
Address: Telephone number: ...

CHIEF COMPLAINT

MEDICAL HISTORY
Yes No
( ) ( ) Is your child receiving medical treatment at present ?....................................
( ) ( ) Is your child currently taking any medication? ....................................
( ) ( ) is your child allergic to any medications (e.g. Penicillin) or any other
substance?
( ) ( ) Has your child ever been hospitalized ?....................................................
Has your child had problems with the following: Yes No
Yes No
Yes No
( ) ( ) Cardiovascular
( ) ( ) Bleeding
( ) ( ) Asthma
( ) ( ) Hepatitis/Jaundice ( ) ( ) Diabetes
( ) ( ) Seizures/Epilepsy
( ) ( ) Kidney/Renal
( ) ( ) Speech
( ) ( ) Other
Additional information or any explanation:

DENTAL HISTORY
Yes
( )
( )
( )

No
( ) Is this your childs first dental visit?
( ) Has your child ever had unfavorable dental experience?
( ) Does your child brush his/her teeth?
If yes how many times?{.} per
( ) ( ) Does your child use dental floss? If yes how many times?{.} per
( ) ( ) Does someone assist your child with cleaning the teeth?
( ) ( ) Has your child ever taken Fluoride supplements/Vitamins with Fluoride?
( ) ( ) Does your child have/had sucking habit or any abnormal habit (e.g. nail
biting)?

Taibah University
College of Dentistry
Department of Pediatric Dentistry

Has your child ever had any of the following:Yes No

Yes No
Yes No
( ) ( ) Toothache
( ) ( ) Tooth Mobility
( ) ( ) Tooth Abscess
( ) ( ) Bleeding Gums
( ) ( ) Tooth Discoloration
( ) ( ) Other
..
Is there additional information we should be aware of prior to providing dental care
for your child?
....................................................................................................
Guardian's Signature :

DIETARY HISTORY
* Number of main meals
{.} per
* Number of snacks
{.} per
* Number of fresh vegetables
{.} per
* Number of fresh fruits
{.} per
* Number of carbonated or soft drinks
{.} per
* Number of sweets, candy, chocolate or other food containing sugar
{.} per
* Other............................................................................... {.} per

CLINICAL EXAMINATION
Extra-Oral Examination

Intra-Oral Examination

Head/ Face
............
Neck /Nodes
............
Eyes
............
Lips
............
Skin/Hair
............
Other Findings...............................

Pharynx / Tonsils ............

Palate
............
Tongue
............
Floor of Mouth ............
Buccal Mucosa
............
Other Findings ...........................

FUNCTIONAL ASSESSMENT
Breathing:( ) Nose
TMJ: ( ) Normal
Mandibular movement: -

( ) Mouth
( ) Clicking
( ) Normal

( ) Both
( ) Pain
( ) Deviation

PERIODONTAL EVALUATION
( ) Healthy
None
Plaque
Calculus
Staining

( ) Gingivitis
Slight

( ) Periodontitis
Moderate

Heavy

Taibah University
College of Dentistry
Department of Pediatric Dentistry

Injury to Teeth, Jaw, Mouth:

( ) None,

( ) Yes , Indicate which teeth , when and how injury happened.

Dental Anomalies/ Others:

OCCLUSION
Type of dentition:
Molar Relationship:
2nd Primary Molar

Canine Relationship:
1 Permanent Molar

( ) Flush Terminal Plane

( ) Mesial Step
( ) Distal Step

R ( ) L ( ) Class I
R ( ) L ( ) Class II
R ( ) L ( ) Class III

st

R ( ) L ( ) Class I
R ( ) L ( ) Class II
R ( ) L ( ) Class III

Midline:
( ) Normal

Deviated :

R( ) L( )

Cross bite: ( ) None

( ) Anterior R ( ) L ( ) Teeth
( ) Posterior R ( ) L ( ) Teeth....

Incisor Relationship: Overjet:

Overbite

Open bite: .

HARD TISSUE EXAMINATION

Taibah University
College of Dentistry
Department of Pediatric Dentistry

Dental Caries Indices:

D =.. + M = .. + F =..
d =.. + e = .. + f =..
d =.. + m = .. + f =..

DMF =..
def =..
dmf =..

Caries Risk Assessment:

( ) Low Risk

( ) Moderate Risk

( ) High Risk

Child Behavior / Development:

DIAGNOSIS
Diagnosis of Chief Complaint:

.
Diagnosis of other Dental Conditions:

Taibah University
College of Dentistry
Department of Pediatric Dentistry

TREATMENT PLAN
Visit
Number

Tooth/ Teeth
to be treated

Procedure to be done

Notes

Additional comments: .
..
..
Supervisor`s Signature: ..
Date: .