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Chief Complaint
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Referred by
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Currently undergoing ortho
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Prior ortho/tmj tx?
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Habits
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Sleep study ever done?
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S.S. notes (where,when,results?)
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Sleep related symptoms:
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Epworth Score:
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Review of symptoms
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Stomatognathic Exam
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Range of Motion
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ROM WNL
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Comfort Open/Active (w/pain) Open mm
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Passive Open (assisted in mm)
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Laterotrusive (Rt/Lt) (mm).
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Max Protrusion/Retrusion (mm).
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Deflection (doesn't return) mm
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Deviation (pops back) mm
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Midline aligned?
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Notes:
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TMJ eval done?
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Noise heard at:
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TMJ evaluation any pain?
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Other symptoms present
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Muscle palpation pain on
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Palpation notes.
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Bite Maneuvers
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Right separator (ipsi-muscle;contra-tmj)
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Left separator (ipsi-muscle;contra-tmj)
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TMJ/Bite Notes:
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Intraoral Exam:
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Last dental visit on:
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No dental tx needed.
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Dental tx underway:
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Estimated tx completion date:
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Dental relationship [left/right]
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Overjet/overbite (mm)
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Occlusion eval: no contact on
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Other notes...
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Mallampati class
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Soft palate
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Uvula
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Tonsils
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Tongue
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Gag reflex
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Maxilla presents
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Mandible presents
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Bruxism
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Inflammation/Calculus
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Caries/fractures/failing restor
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Pt reports pain on tth #'s:
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Airway tests completed
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Impression:
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Assessment
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Notes
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Treatment Plan:
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Step 1
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Step 2
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Step 3
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Step 4
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Stretching exercises given
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Diagnostic sleep study needed
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HST selected
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Referral to [Dr./sleep clinic]
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Pt will think about it
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Referred back in...
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Any tx/ins notes:
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