This document contains a case history proforma template that includes sections for identifying patient information, chief complaint, medical and dental history, social history, physical examination findings, extraoral and intraoral examination, provisional and differential diagnosis, treatment plan, and follow up. The template guides dental practitioners to collect comprehensive health information about a patient to inform diagnosis and treatment planning.

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)

6. 9)Habit/ Habit Index
Oral Hygiene
Habits
Adverse
Habits
Destructive
Habits
Tooth
Brush
Datoon
-Tooth Powder
-Tooth Paste
-Mouthwashes
Drinking
Smoking
Chewing
-Tobacco
-Gutkha
-Mouth breathing
-Thumb sucking
-Tongue thrusting
-Nail biting
-Lip biting

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

11. 8) Root piece
9) Fractured teeth
10) Stain/ Calculus
11) Wasting disease ( Attrition/ Abrasion/
Erosion/ Abfraction)
12) Impacted tooth/ teeth
13) Developmental disturbances
14) Malocclusion ( Angle's classification)

12. Soft Tissues
1) Gingiva
2) Mucosa ( Alveolar/ Buccal/ vestibular/
Labial/ Lingual)
3) Lip
4) Tongue
5) Floor of the mouth
6) Hard and Soft Palate
7) Tonsils
8) Uvula
9) Retromolar Pad region

13. L) Provisional diagnosis
M) Differential diagnosis
N) Investigation
O) Final diagnosis

14. P) Treatment Plan
Immediate Planned
1) Medication
2) Incision and
Drainage
3) Dental treatment
(extraction)
Medical Dental
-Scaling and Prophylaxis
-Oral Surgical procedures
-Conservative procedures
-Prosthetic procedures
-Occlusal Rehabilitation
-Orthodontic procedures
-Oral Hygiene instructions
Q) Follow up