ORAL EXAM by liaoqinmei

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									                       Physician: __________________________________________
                       Patient Name: ______________________________________
                       Date: ______________ Age: __________ Sex: ___________




                                          ORAL EXAM




      PERMANENT DENTITION                                      MIXED DENTITION
                                                   Upper Labial Frenum: ____________________
Tooth Missing: M
                                                   Lower Labial Frenum: ____________________
Tooth Blocked Out: B
                                                   Lingual Frenum: __________________________
Supernumerary Tooth: S


Upper Dental Midline: ________________________     Lower Dental Midline: ____________________

Upper Skeletal Midline: ______________________     Lower Skeletal Midline: __________________


                                                   Please Circle
Molar Class:    Left________     Right_________
                                                   · Soft Tissue Perio
Cuspid Class: Left________       Right_________
                                                   Excellent
Crossbite: _____________________________________   Average
                                                   Poor
Reverse Crossbite: ___________________________
                                                   Very Poor
Vertical Dimension: __________________________
                                                   Please Circle
Overjet: _______________________________________
                                                   · Hard Tissue Perio

                                                   Excellent
                                                   Average
                                                   Poor
                                                   Very Poor
                                             TMJ EXAM
Range of Vertical Motion: ______________                          CHART JAW OPENING
Opening Deviation: L _______     R _______

Closing Deviation: L _______     R _______

Opening Click:       L _______   R _______

Closing Click:       L _______   R _______

Pain in TMJ:         L _______   R _______

Head & Neck Pain: L _______      R _______

Left Lateral: ____________________________

Right Lateral: ___________________________


AIRWAY                                                       R                 Millimeters          L
                                                             Ears
Mouth Breathing:     Y              N

Tonsils:             Y              N                        Eustachian Tubes: L ______       R ______

Adenoids:            Y              N                        Pain:         L ______    R ______

High Palate:         Y              N                        Drainage:     L ______    R ______

Turbinate:           Y              N                        Tinnitus:     L ______    R ______

                                                             Vertigo:      Y            N



Diagnostic Records

1. Orthodontic Study Models Enclosed: ________________________________________________________

2. Fabricate Orthodontic Study Models: ________________________________________________________

3. Cephalometric Radiograph: __________________________________________________________________

4. Panoramic Radiograph: ______________________________________________________________________

5. TMJ Radiographs: ____________________________________________________________________________

6. Photographs:      Five Intra-oral: _______________   Three Extra-oral: _______________________


               Clinical Foundation of Orthopedics, Orthodontics & TMJ
                                                      PO Box 695
                                                  Gainesville, TX 76241
                                        Tel: 800.406.2366 Fax: 940.612.3908
                                        Email: skipcfoo@suddenlink.net
                                        WWW.CFOO.COM

								
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