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Clinical Examination

Patient Name

Patient Number

Date of Birth

Patient Email

Parent/Guardian Name

Parent/Guardian Email

Family Dentist Name

Family Dentist Email

Age

YO

Race

Sex

Puberty

At Age

Dental IQ

Chief Complaint

Oral Habits

Contributory Medical History

Contributory Dental History

Face

Facial Pattern

Facial Symmetry

Facial Profile

Chin

Maxillary and Mandibular Incisors

Nose

Lips

Incisal Display Percentage

%

Naso-Labial Angle

Mental Fold Angle

Chin-Throat Angle

Antero-Posterior Relationship

Angle Classification

Subdivision

Overjet

mm

- mm

Maxilla

Mandible

Anterior Crossbite

Vertical

Overbite Percentage

%

Openbite

mm

mm

Traverse

Posterior Crossbite

Function

Centric Relation/Centric Occlusion Discrepancy

Centric Relation / Centric Occlusion Discrepancy mm

Maximum Opening

mm

Midline Relationship Maxilla

mm

Midline Relationship Mandible

mm

Deviation on Opening

mm

Deviation on Protusion

mm

TMJ

TMJ Symptoms

TMJ Sound Opening

TMJ Sound Closing

Periodontal Tissue

Hygiene

Attached Gingiva

Gingival Recession

Frenum Pull

Teeth Present in Oral Cavity

Permanent Dentition

8	7	6	5	4	3	2	1	1	2	3	4	5	6	7	8


8	7	6	5	4	3	2	1	1	2	3	4	5	6	7	8

Primary Dentition

E	D	C	B	A	A	B	C	D	E


E	D	C	B	A	A	B	C	D	E

Teeth with Concerns

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Timestamp

Audit

September 14, 2020 4:00 pm MST

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