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CC & HPI
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Chief Complaint
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Subjective Symptoms
• • •
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Previous Therapies
• • •
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Comments
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ORAL HEALTH
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Perio
• • •
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Perio Details
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Dental
• • •
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Dental Details
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OCCLUSION
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Occlusion Angle Classification (Right)
• • •
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Occlusion Angle Classification (Left)
• • •
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Overbite: ___ mm
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Overjet: ___ mm
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Additional Occlusion
• • •
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Evidence of Bruxism
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Dental Midline Position
• • •
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Deviation Measurement (Right): ___ mm
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Deviation Measurement (Left): ___ mm
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RANGE OF MOTION
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Vertical Interincisal Opening: ___ mm
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Right Mandibular Lateral Excursion: ___ mm
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Left Mandibular Lateral Excursion: ___ mm
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MIN Retrusive Range: ___ mm
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Max Protrusive Range: ___ mm
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MATRx Retrusive Range: ___ mm
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MUSCLE & JOINT
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Right Masseters Palpation
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Left Masseters Palpation
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Right Temporalis Palpation
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Left Temporalis Palpation
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Right Sternocleidomastoid Palpation
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Left Sternocleidomastoid Palpation
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Right Lateral Pterygoid Palpation
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Left Lateral Pterygoid Palpation
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Right Auricular Region Palpation
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Left Auricular Region Palpation
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Right Digrastic Palpation
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Left Digrastic Palpation
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Right Temperomandibular Joint Auscultation
• • •
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Left Temperomandibular Joint Auscultation
• • •
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Airway (Pharyngeal & Laryngeal Tissue)
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Mallampati
• • •
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New Free Draw
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Tonsils
• • •
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New Free Draw
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Tongue
• • •
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Soft Pallate
• • •
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Maxilla
• • •
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Mandible
• • •
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Uvula
• • •
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Gag Reflex
• • •
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Nasal Passage
• • •
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Respiration
• • •
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