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Comment on findings:
B. Chart diseases, abnormalities and
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u
OR
Comment on findings:
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II Periodontal Evaluation
A. Chart periodontal probings, gingival recession, and mobility
Buccal
Lingual
Buccal
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Lingua)
Lingual
§
Buccal
Lingual
Buccal
..
0 No Disease 0 Class I: Gingivitis
0 Class II: Early Periodontitis
0 Class III: Moderate Periodontitis
0 Class IV: Advanced Periodontitis
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V. Bruxism
Q No history of bruxism
Q History of bruxism
Please describe any bruxism habit, presence of wear facets or need for occlusal guard:
VI. Prosthesis
Q No prosthesis present
Q Prosthesis present
Please describe the nature and extent of the prosthesis (e.g. full or partial dentures, bridge, etc.)
and the need for repair or replacement:
VII. Treatment
List all treatment completed after this examination. Do not include treatment planned but not yet completed.