Choosing the Right CBSE School A Comprehensive Guide for Parents
Case history
1. CASE HISTORY
PROFORMA
Guided by: Dr.Bhumi Patel Batch: 2012-2016
("G"-Roll no:85-100)
2. A) Identification Data
1) Date
2) Registration number
3) Name
4) Age/Sex
5) Address
6) Occupation
7) Education
3. B) Chief Complaint
C) History of Present Illness
D) Past Medical History
-Diabetes /Hypertension/ Asthma
/Allergy/ Drug History/ Pregnancy/
Hospitalization/ Blood transfusion
etc....
4. E) Past Dental History
F) Social History
G) Family History
5. H) Personal History
1) Religion
2) Marital status
3) Diet
4) Appetite
5) Bowel and bladder movement
6) Micturition
7) Sleep
8) Stress (physical/mental)
7. I) General Examination
1) Consciousness
2) Built
3) Gait
4) Posture
5) Physical deformities
6) Skin (normal/ pallor/ cyanosis/ icteric)
7) Nails
8) Body mass index
9) Vital signs
Pulse Blood Pressure Temperature Respiratory Rate
8. J) Extra Oral Examination
1) Head
2) Hair
3) Eyes
4) Nose
5) Ear
6) Facial symmetry
7) Mouth opening
8) Temporomandibular joints
9) Lymph nodes
10) Salivary glands
9. 11) Congenital/ Post surgical defects/
Scars/ Bruise
12) Referred pain
13) Neck
14) Muscles of Mastication
10. K) Intra Oral Examination
Hard Tissue
1) Tooth number system
2) Number of teeth
3) Present teeth
4) Missing teeth
5) Caries in teeth
6) Restoration/ Crown/ Bridge
7) Mobility of teeth