This document contains a dental examination form assessing a patient's chief complaint, medical history, dental history, subjective findings from clinical tests, objective clinical findings, radiographic findings, and diagnosis. The subjective findings section notes the patient's response to thermal, mechanical and pressure stimuli. The objective findings include electrical pulp testing responses and tenderness. Radiographic findings list possible periapical conditions and other findings relevant to diagnosis or treatment. The diagnosis conclusions include classifications of normal pulp, reversible/irreversible pulpitis, necrotic pulp, periapical conditions, and other options.

1. 1. Subjective Findings
Chief Complain:
Significant Medical History:
History of tooth (Mark all appropriate):
1 Trauma 6 Pulp cap
2 Caries 7 Pulpotomy
3 Carious exposure 8 RCT
4 Mech. Exposure 9 ______________
5 Restoration
Reaction to thermal stimulus:
0 None 1 Short
2 Continuous
Reaction to Mastication:
0 None 1 Mild – moderate
2 Severe
Nature of pain:
0 None 1 Spontaneous
2 Diffuse 3 Localized
Duration of pain:
4 Short 5 Prolonged
2. Objective Findings
Electrical pulp tester:
Tooth No. Response No response
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Reaction to thermal stimulus:
0 None 1 Short 2 Prolonged
Reaction to direct dentin stimulus:
0 None 1 Response
Tender to palpation of overlying mucosa:
0 NO 1 Yes
Reaction to percussion:
0 None 1 Mild – moderate
2 Severe
Swelling:
0 Absent 1 Present
Sinus Tract:
0 Absent 1 Present
Caries excavation:
0 No exposure 1 Exposure
Periodontal status of suspected tooth:
0 Normal
1 Excessive Mobility ( 1 + 2 + 3 +)
2 Significant periodontitis
Explain: _______________
3. Radiographic Findings
Periapical radiographic findings:
0 Normal
1 Thickened periodontal ligament space
2 Apical radiolucency < 10 mm
3 Apical radiolucency > 10 mm
4 Apical root resorption
5 Apical radiopacity
6 Furcal radiolucency
Other significant findings affecting diagnosis
and / or treatment ( Anatomy, isolation,
calcifications, etc.. )
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4. Diagnosis
1 Normal
2 Reversible pulpitis
3 Irreversible pulpitis
4 Necrotic pulp
5 Not applicable
6 Normal PDL
7 Acute apical periodontitis
8 Chronic apical periodontitis
9 Suppurative apical periodontitis
10 Acute apical abscess
11 Condensing osteitis
12 Other ______________