Headings
Chief complaint · Medical history · Dental history · Extraoral exam · Intraoral exam · Periodontal charting · Radiographs · Diagnosis · Treatment plan
When to use it
Use this for a patient’s first comprehensive visit to your practice, when you need a full baseline. It captures medical and dental history, a full periodontal chart and a complete radiographic series in one record. Unlike a periodic exam, it assumes you know nothing yet and ends with a full diagnosis and a phased plan.
Example
Fictional example
Chief complaint
Wants a checkup. Last dental visit five years ago. Food packs between lower left molars.
Medical history
Hypertension, controlled on lisinopril. No known drug allergies. Nonsmoker.
Dental history
Irregular care. Brushes once daily, rarely flosses. Several fillings as a teenager.
Extraoral exam
TMJ within normal limits. No lymphadenopathy. Lips and skin normal.
Intraoral exam
Soft tissues healthy. Open contact with recurrent decay #19 MO. Fractured distolingual cusp #30.
Periodontal charting
Generalized 2 to 4 mm. 5 mm distolingual #31. Light bleeding on posteriors.
Radiographs
Full mouth series. Caries #19 into dentin. Mild horizontal bone loss lower right.
Diagnosis
Recurrent caries #19. Fractured cusp #30. Localized mild periodontitis, lower right.
Treatment plan
Scaling and root planing lower right. MOD composite #19. Crown #30. Re-evaluate gums in 6 weeks.