Patients Personal Details

For office use

Form 1
D D M M Y Y CHI Number
Permanent Address

Please write clearly Title (Please tick appropriate box) Mr Mrs Ms Miss

Other (Please state below)

Surname Postcode Forename Email Address

Contact Phone No. Sex Male Female Doctors Name Year Doctors Address

Date of Birth Day Month

Family Name at Birth

Occupation

If retired, previous occupation

Postcode Doctors Phone No.

Ethnicity (Please tick appropriate box) White Black, Black British, Black Scottish Asian, Asian British, Asian Scottish Mixed (Please state) Other ethnic background (Please state)
PTO

Patients Personal Details

Form 1 (cont.)

If you are filling in this form on behalf of the patient, please also enter YOUR OWN details below. Surname Forename

Relationship to Patient Parent/Guardian Carer Other family member Other (Please state)

Address
(If different from patients permanent address)

If you are a carer, please state how long you have attended the patient. Months Years

Postcode Phone No.

Additional Information

After you have completed this form please return it to a member of the Dental Team. Signature of Patient, Parent or Carer Date

Social and Dental History

For office use

Form 2
D D M M Y Y CHI Number
Forename

Please write clearly Surname

When did you last see a dentist? (If you cannot remember please tick the option most likely) Within the past 6 months More than 2 years ago Please tick appropriate box Have you received any dental treatment under local anaesthetic (injection in the gum)? If yes, please note whether it caused you any problems Do you currently have any problems or concerns with your teeth, gums or mouth? Do you play a sport where you have the potential to damage your teeth? Do you wear a denture, brace or retainer? As far as you are aware do you grind or clench your teeth? Do you have a family history of gum disease (periodontitis)? Are you anxious or nervous about attending the dentist? Which of the following do you use each day? (Please tick appropriate boxes) Fluoride toothpaste Fluoride tablets or drops Sugar-free chewing gum Dental floss or any other oral health Mouthwash Not applicable 6 months to 1 year ago Never been to the dentist Yes No Unsure Further details 1 - 2 years ago

Which of the following do you have each day? (Please tick appropriate boxes) Sugary carbonated (fizzy) drinks Diet carbonated (fizzy) drinks Sugar in hot drinks
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Around 5 portions of fruit and vegetables Sugary treats (sweets and biscuits) between meals

Social and Dental History

Have you ever used chewing tobacco, paan, gutkha supari or beetle quid?
(Please tick appropriate box)

Form 2 (cont.)
Yes No Unsure Please specify

Smoking Status (Please tick appropriate box) I have never smoked I am an ex-smoker I am a smoker Alcohol Consumption 1 unit of alcohol = half a standard 175ml glass of wine (12.5% abv) half a pint of normal strength beer, lager or cider (4% abv) one 25 ml measure of spirits (40% abv) units units Number of years an ex-smoker Number of cigarettes etc smoked per day

On average how many units do you drink in a week? What is the largest number of units you drank in a single day in the last week? All Patients In your view, how likely is it that the health of your teeth will affect your overall wellbeing?
(Please tick appropriate box)

1
Not likely at all

5
Very likely

Additional Information

After you have completed this form please return it to a member of the Dental Team. Signature of Patient, Parent or Carer Date

Medical History
For office use

Form 3
D D M M Y Y CHI Number
Forename

Please write clearly Surname

Please tick appropriate box. If you have further details, including any allergies or pills, tablets or other medication that you take, please enter them in the Further Details box. Yes Are you aware of anything that you are allergic to? (penicillin or another antibiotic, pollen, latex, food, jewellery or any other substance) Have you ever had any heart problems/conditions? (blood pressure problems, angina or chest pains, pacemaker or any other heart or blood vessel condition) Have you ever had any chest or breathing problems/conditions? (asthma, bronchitis or any other breathing problems) Have you ever had any stomach, gut, liver or kidney problems/conditions? Do you have any blood or bleeding problems/conditions? Are you prone to fits/faints or do you have epilepsy? Do you have any problems or conditions relating to your bones, joints or muscles? (arthritis, muscle weakness or any other condition) Do you have hepatitis, HIV, AIDS or tuberculosis (TB)? Are you pregnant or is there a possibility you could be pregnant? Do you have diabetes? Do you have a medical condition or problem not specified above? Are you currently under treatment from a doctor, consultant or clinic? Do you carry a medical warning card? Are you taking or meant to take medicine prescribed by your doctor or otherwise? (tablets, pills, patches, medicines, inhalers, ointments, injections, oral contraceptives, herbal remedies, recreational drugs, recent vaccinations). If yes, please enter them in the Further Details box overleaf. Are there any conditions that run in your family? (diabetes, sickle cell disease or any other conditions). If yes, please enter them in the Further Details box overleaf. Have you ever had an illness or operation that required hospital treatment? If yes, please enter them in the Further Details box overleaf.
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No Unsure

Medical History
Visual impairment Communication difficulties Wheelchair user Hearing difficulties Mental health difficulties Hoist transfer required

Form 3 (cont.)
Learning difficulties Physical disability None

Additional Requirements or Special Needs (Please tick appropriate box or boxes)

Other (Please give details if appropriate)

If you are an armed forces veteran, please tick here Further Details including any allergies or pills, tablets or other medication that you take

After you have completed this form please return it to a member of the Dental Team. Signature of Patient, Parent or Carer Date

Patient History Update

Patient Name
For office use

D D M M Y Y

CHI Number
For returning patients, review the patient history forms completed previously and ensure that the information provided is up to date and accurate. Changes can be recorded below. Date Changes Signature of Patient, Parent or Carer

Dental Anxiety Questionnaire

For office use

Form 4
D D M M Y Y CHI Number
Forename

Please write clearly Surname

Please fill in part A (below) or part B (overleaf). Choose the side that suits you best. A Please tell us how anxious you get about your dental visit? (Please tick appropriate box) If you went to your dentist for treatment tomorrow, how would you feel? Not Anxious Very Anxious Slightly Anxious Extremely Anxious Fairly Anxious

If you were sitting in the waiting room (waiting for treatment), how would you feel? Not Anxious Very Anxious Slightly Anxious Extremely Anxious Fairly Anxious

If you were about to have a tooth drilled, how would you feel? Not Anxious Very Anxious Slightly Anxious Extremely Anxious Fairly Anxious

If you were about to have your teeth scaled and polished, how would you feel? Not Anxious Very Anxious Slightly Anxious Extremely Anxious Fairly Anxious

If you were about to have a local anaesthetic injection in your gum, above an upper back tooth, how would you feel? Not Anxious Very Anxious Slightly Anxious Extremely Anxious Fairly Anxious

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Dental Anxiety Questionnaire

Form 4 (cont.)

B For the next 6 questions I would like you to show me how relaxed or worried you get about the dentist and what happens at the dentist. To show me how relaxed or worried you feel, please use the simple scale below. The scale is just like a ruler going from 1, which would show that you are relaxed, to 5, which would show that you are very worried. (Please circle the appropriate number on the scale).

1 would mean: relaxed/not worried 2 would mean: very slightly worried 3 would mean: fairly worried
How do you feel about... ...going to visit the dentist? ...having your teeth looked at? ...having your teeth cleaned and polished? ...having an injection in the gum? ...having a filling? ...having a tooth taken out? Additional Information 1 1 1 1 1 1

4 would mean: worried a lot 5 would mean: very worried

2 2 2 2 2 2

3 3 3 3 3 3

4 4 4 4 4 4

5 5 5 5 5 5

After you have completed this form please return it to a member of the Dental Team. Signature of Patient, Parent or Carer Date

Assessment of Head and Neck

For office use

Form 5
D D M M Y Y CHI Number
Examination Date

Surname Forename Age Sex

Day

Month

Year

Assessment of: Please tick boxes when examination is completed Skin (including swellings) TMJ Facial bones Lymph nodes

Note of abnormalities found

Please circle as appropriate, if an abnormality is found in the following groups of lymph nodes.

I VI

II III IV V V III IV

II

I VI
Referral (Please tick) No referral required Non-urgent referral Urgent referral

Signature of Practitioner

Date

Assessment of Oral Mucosal Tissue

For office use

Form 6
D D M M Y Y CHI Number
Examination Date

Surname Forename Age Sex

Ulcer a. Upper lip b. Lower lip c. R commissure d. L commissure e. Upper labial mucosa f. Upper sulci g. Upper gingivae h. Hard palate i. j. l. Soft palate Pharynx and tonsillar area Tongue - R lateral border White Red Swelling Pigmented Other

Day

Month

Year No

Abnormal findings Yes

If yes, use the list on the left and / or the diagram overleaf to note details of any abnormal finding. Referral (Please tick) No referral required Non-urgent referral Notes Urgent referral

k. Tongue - dorsum m. Tongue - L lateral border n. Tongue - ventral o. Floor of mouth p. R buccal mucosa q. L buccal mucosa r. Lower gingivae s. Lower sulci t. Lower labial mucosa

Signature of Practitioner

Date
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Assessment of Oral Mucosal Tissue

Record the extent of any pathology on the mouth map and describe it below: Description and notes:

Form 6 (cont.)

Monitoring 1 Date Signature of Practitioner

Monitoring 2 Date Signature of Practitioner

Monitoring 3 Date Signature of Practitioner

Has lesion changed since previous examination? Lesion description / Notes

Yes

No

Has lesion changed since previous examination? Lesion description / Notes

Yes

No

Has lesion changed since previous examination? Lesion description / Notes

Yes

No

Signature of Practitioner

Date

Assessment of Teeth
Assessment of Teeth
Surname Surname Given Name CHI Number
For office use

CHI Number

D D M M Y Y

Form 7 D D M M Y Y

Form 7

Forename Age
Age

Examination Date Date Month Sex

Sex Examination date Day

Year

Month

Year

R
o 55 54 53 52 51 61 62 63 64 oo 65

o 18 48 17 47

o 16 46 15 45 14 44 13 43

o 23 33 24 34 25 35 26 36

o 27 37 28 38

12 42

11 41

21 31

22 32

o 85 84 83 82 81 71 72 73 74 75

R
o o

L
Basic Full Full Date

TypeType of examination completed: Basic of examination completed:

Draft 02.1 of Practitioner Signature

Signature of Practitioner

Date

Basic Periodontal Examination and Dentition Care Requirements

For office use

Form 8
D D M M Y Y

Surname Forename Age Sex

CHI Number
Examination Date Day Month Year

Basic Periodontal Examination Code Visible Signs 0 1 2 No bleeding or pocketing detected Bleeding on probing; no pocketing Plaque-retentive factors present; no pocketing >3.5 mm Code Visible Signs 3 4 * Pockets >3.5 mm but <5.5 mm in depth Pockets >5.5 mm in depth Loss of attachment of 7 mm or presence of furcation involvement

Dentition Care Requirements Prevention New Restoration Re-restoration Extraction Other Notes

Signature of Practitioner

Date

Radiographic Assessment
For office use

Form 9
D D M M Y Y CHI Number
Examination Date

Surname Forename Age Sex Quality of films taken R R Lower Lateral Ceph Other L L Periapical

Day

Month

Year

Type of film(s) Bitewings Occlusal Extra-oral Horizontal Vertical Upper OPG

Radiation Dose / Setting

Clinical indication for taking film(s), and suspected diagnosis

Radiographic Report

Clinical examination undertaken by: Date Films authorised by: Date Films taken by: Date

Signature of Practitioner

Date

Assessment of Dentures (if required)

For office use

Form 10
D D M M Y Y CHI Number
Examination Date

Surname Forename Age Sex Yes No Unsure

Day

Month

Year

Patients Assessment of Dentures

Are you happy with the appearance of your dentures? Do your dentures move? Are your dentures comfortable? Do your dentures affect your speech? Are you able to chew adequately? Are you able to bite adequately?

Clinicians Assessment of Dentures

Denture Base Material Acrylic Cobalt Chrome Type of Denture F/F P/F P/ P/P F/ /P F/P /F

Denture Hygiene Good Fair Poor

Upper Denture Tissue adaption Base extension Labial Buccal Posterior border Tuberosity Labial fullness

Good Poor

N/A Incisal level Incisal plane Position of posterior teeth Occlusal plane level Occlusal plane orientation Arch width Buccallingual width

Good Poor

N/A

Alteration proposed / Notes

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Assessment of Dentures (if required)

Lower Denture Tissue adaption Base extension Labial Buccal Posterior border Lingual Distolingual Good Poor N/A Labial fullness Position of posterior teeth Occlusal plane level Arch width Buccallingual width Cusp form Good Poor N/A

Form 10 (cont.)
Alteration proposed / Notes

Relationship of Dentures
Occlusal Position Retruded Protruded Intercuspal / Muscular
(Select one)

Alteration proposed / Notes Occlusal Contacts Articulation Occlusal vertical dimension Incisal overjet Incisal overbite Good Poor N/A

Aesthetics
Good Poor Mould / Arrangement Shade

Alteration proposed / Notes

Signature of Practitioner

Date

Patient Review and Personal Care Plan

A summary of the status of your oral health is summarised below with details of when your next review or assessment will be. Surname Dentists Details

Forename

Examination Date Day Month Year Phone No.

Assessment of Oral Health Status

High Risk

Medium Risk

Low Risk

Soft tissue disease assessment Gum disease assessment Tooth decay assessment Other assessment (details below)

Overall risk of future dental problems Your next review or assessment

After your treatment is complete, your next check-up with your dentist / hygienist / nurse will be in:

patient under 18 years 3 months 9 months 6 months 12 months

patient 18 years and over 3 months 12 months 21 months 6 months 15 months 24 months Full assessment 9 months 18 months

Type of assessment

Focussed review

If you have problems or concerns about your oral health before your next scheduled visit, contact your dental practice.
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Patient Review and Personal Care Plan (cont.)

Things you can do to maintain or improve your oral health are shown below followed by what the dental team plans to do. Actions for the Patient

Actions for the Dental Team Prevention

Treatment

Maintenance

Referral

Signature of Patient, Parent or Carer

Date

Signature of Practitioner

Date

Oral Health Assessment and Review Checklist

Patient Name
For office use

D D M M Y Y

CHI Number
Date of Assessment Assessment Type FOHR / OHA
Yes

Day
No

Month
Comment

Year

Patient Histories Completed/Updated* Personal details Social history Dental history Medical history Dental anxiety level Dentist reviewed histories Clinical Assessment Completed/Updated* Head and neck Oral mucosal tissue Periodontal tissue (BPE/plaque scores) Teeth - Caries and restorations - Tooth surface loss - Tooth abnormalities - Fluorosis - Dental trauma Occlusion Orthodontic needs Dentures
*Record full details of any significant findings separately.

*If new patient, complete new forms; if returning patient, ask patient if anything has changed and review forms completed previously

Yes

No

Comment

Yes

No

N/A

Good Effectiveness of treatment Yes Patient compliance with advice Risk Assessment Oral mucosal disease Periodontal disease Caries Other (please note) High

Poor No Medium

N/A

Comment

Low

Comment

OVERALL RISK Yes Prevention advice given Preventive treatment required Operative treatment required Review Interval (months) (following completion of any treatment): 3 6 9 12 15 Proposed date for next OHA (following completion of any treatment): No Change Change Personal Care Plan Review Comment 18 21 24 No Comment