DEPT.

OF CONSERVATIVE DENTISTRY AND ENDODONTICS

CASE RECORD
Doctors Name:
Pt. Name: Age/Sex: Occupation: Marital Status: Married / Single Address / Ph. No.: DENTAL HISTORY: Chief Complaint:

S.No.
O.P. No.: Date:

History of resent Illness:

ast Dental History:

AST !EDICAL HISTORY: ANY RELATED DISEASES TO : Cardiovascular !espirator" #astrointestinal Neural () "es* give details: ALLER"IC TO: ave "ou &een hospitali+ed / Operated: () Yes* give details: Do "ou have an" histor" o) a&normal &leeding ,ith trauma or: dental procedures. () "es* give details: Are "ou pregnantI TRI!ESTER II TRI!ESTER Yes # No Yes # No Yes # No : : : : Yes/No Yes/No Yes/No Yes/No epatic !enal $ndocrine %Dia&etes' : : : Yes/No Yes/No Yes/No

III TRI!ESTER

CLINICAL E$A!INATION: I.INTRA ORAL E$A!INATION: A.HARD TISS%E E$A!INATION: No o) teeth present : Missing teeth : .illed teeth : .ractured teeth : Discoloured teeth : /asting diseases : Mo&ilit" : Cro,ding/spacing : Molar occlusion : &.SO'T TISS%E E$A!INATION: S,elling : Sinus opening : (nspection:

Palpation: Percussion:

II.E$TRA ORAL E$A!INATION: S,elling : 0"mphnode enlargement: Sinus opening : RO(ISIONAL DIA"NOSIS:

%L (ITALITY TEST: 1 Cold 2hermal 2est: Normal A&normal !esponse: 1 $lectric Pulp 2est: Control tooth response to No.: 2est tooth response at No.: ERC%SSION TEST: eat No response

RADIOLO"ICAL E$A!INATION:

OTHER TESTS: LA& IN(ESTI"ATIONS: 'INAL DIA"NOSIS: RO"NOSIS: #ood / .air / Poor / Dou&t)ul. TREAT!ENT LAN:

Patient Motivation: ighl" / Moderatel" / Poorl" Si)nat*re OST O ERATI(E E(AL%ATION + 'OLLO, % 3 Month 4 Months 5 Months 3 Year

CONSENT 'OR!
3. 6. 4. 9. <. 2he doctor has explained m" dental condition* the proposed procedure* ( understand the pro&a&le out come o) the procedure including that ,hich are speci)ic to me. 2he doctor has explained relevant treatment options and their associated ris7s. 2he doctor has explained m" prognosis the procedure. ( understand that photographs or video )ootage ma" &e ta7en during the procedure out o) academic interest. %You shall not &e identi)ied in an" photograph / 8ideo )ootage'. ( :nderstand the details o) the procedure and in case o) an" unexpected complication during or su&se;uent to treatment* ,ill not hold either the treating doctor or the hospital authorit" responsi&le. ( am ,illing to undergo the treatment.

Si)nat*re - arent # "*ar.ian/ if minor

AY!ENTS AND RECEI TS

&ill No. Amo*nt ai.

Date

Treatment Done

!e.ication s

Si)nat*re

ENDODONTIC CASE RECORD

Pt. Name: 2ooth Num&er: Access Cavit" Preparation and Pup $xtripation:

Date:

=io>Mechanical Preparation: 0ength determination:

(nstruments used: (rrigants used: O&turation: Complete / Sectional Mastercone si+e: Sealer used: Condensation techni;ue: 0ateral / 8ertical / 2hermal Post Operative ?>!a": Apical Seal: 0ateral Condensation:
6

O6 / Saline/NaOCl/Metrog"l/Chlorhexidine

Post $ndodontic !estoration:

Post Operative .ollo, up:

Si)nat*re

RADIO"RA HIC INTER RETATION

No. o) 2eeth present: $xisting !estorations: !ediographic pulp exposure: 0amina dura: Periapical rediolucenc": a. No o) teeth involved &. Si+e and Shape c. Nature o) radiolucenc" Periodontal Status: a. Periodontal space ,idening &. (nterdental &one loss Name o) root canal in the involved teeth: a. No. o) canal &. Shape c. Anatomical variations d. Patenc" e. Presence o) calci)ied structures* resorption* closure o) apical portion Previous endodontic treatment: a. Status o) root canal )illing &. Status o) retrograde )illing .racture o) teeth: a. Cro,n &. !oot An" other a&normalities: