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Dental History
Name :
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Age :
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Gender :
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Form Inputs
Date of Surgery
Referring Clinician
Race
Sinhala
Tamil
Muslim
Other
Clinic
BHT/Case
Name of Hospital
Previous biopsy
No
Yes
If yes: Path No:
Diagnosis
History, Clinical Features and other findings.
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Age :
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Gender :
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Radiological findings
Include radiographs when ever possible:radiographs will be returned
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Age :
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Gender :
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Age :
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Age :
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Treatment Details
Teeth Name
Code
Treatment
Treatment 00
Treatment 01
Treatment 02
Treatment 03
Treatment 04
Treatment 05
Treatment 06
Treatment 07
Treatment 08
Treatment 09
Treatment 10
Treatment 11
Treatment 12
Treatment 13
Treatment 14
Treatment 15
Treatment 16
Treatment 17
Treatment 18
Treatment 19
Treatment 20
Treatment 21
Treatment 22
Treatment 23
Treatment 24
Treatment 25
Treatment 26
Treatment 27
Treatment 28
Treatment 29
Remarks
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Name
Treatment
Remarks
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Name :
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Age :
-
Gender :
-
Form Inputs
Date of Surgery
Referring Clinician
Race
Sinhala
Tamil
Muslim
Other
Clinic
BHT/Case
Name of Hospital
Previous biopsy
No
Yes
If yes: Path No:
Diagnosis
History, Clinical Features and other findings.
Next
Form Inputs
Duration
Site of Lesions's:
Extra osseous
Intra osseous
Description of Lesion's
Size
Colour
Shape
Consistency
Description
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Duration
Site of Lesions's:
Extra osseous
Intra osseous
Description of Lesion's
Size
Colour
Shape
Consistency
Description
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Previous
Treatment History
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Diagnosis
Hospital Name
Referring Clinician
Description
