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1. CASE RECORD
Doctors Name: S.No.
Pt. Name: O.P. No.:
Age/Sex: Date:
Occupation:
Marital Status: Married / Single
Address / Ph. No.:
DENTAL HISTORY:
Chief Complaint:
History of Present Illness:
Past Dental History:
PAST MEDICAL HISTORY:
ANY RELATED DISEASES TO :
Cardiovascular : Yes/No Hepatic : Yes/No
Respiratory : Yes/No Renal : Yes/No
Gastrointestinal : Yes/No Endocrine
(Diabetes)
: Yes/No
Neural : Yes/No
If yes, give details:
ALLERGIC TO:
Have you been hospitalized / Operated: Yes / No
If Yes, give details:
Do you have any history of abnormal bleeding with trauma or: Yes / No
dental procedures.
If yes, give details:
Are you pregnant? Yes / No
I TRIMESTER II TRIMESTER III TRIMESTER
DEPT. OF CONSERVATIVE DENTISTRY AND
ENDODONTICS

2. CLINICAL EXAMINATION:
I.INTRA ORAL EXAMINATION:
A.HARD TISSUE EXAMINATION:
No of teeth present :
Missing teeth :
Filled teeth :
Fractured teeth :
Discoloured teeth :
Wasting diseases :
Mobility :
Crowding/spacing :
Molar occlusion :
B.SOFT TISSUE EXAMINATION:
Swelling :
Sinus opening :
• Inspection:
• Palpation:
• Percussion:
II.EXTRA ORAL EXAMINATION:
Swelling :
Lymphnode enlargement:
Sinus opening :
PROVISIONAL DIAGNOSIS:
PULP VITALITY TEST:
– Cold
Thermal Test: Normal Abnormal Response: No response
– Heat
Electric Pulp Test: Control tooth response to No.:
Test tooth response at No.:
PERCUSSION TEST:

3. RADIOLOGICAL EXAMINATION:
OTHER TESTS:
LAB INVESTIGATIONS:
FINAL DIAGNOSIS:
PROGNOSIS: Good / Fair / Poor / Doubtful.
TREATMENT PLAN:
Patient Motivation: Highly / Moderately / Poorly
Signature
POST OPERATIVE EVALUATION & FOLLOW UP
1 Month
3 Months
6 Months
1 Year
CONSENT FORM
1. The doctor has explained my dental condition, the proposed procedure, I understand the probable
out come of the procedure including that which are specific to me.
2. The doctor has explained relevant treatment options and their associated risks. The doctor has
explained my prognosis the procedure.
3. I understand that photographs or video footage may be taken during the procedure out of academic
interest. (You shall not be identified in any photograph / Video footage).
4. I Understand the details of the procedure and in case of any unexpected complication during or
subsequent to treatment, will not hold either the treating doctor or the hospital authority responsible.
5. I am willing to undergo the treatment.
Signature
(Parent / Guardian, if minor

4. PAYMENTS AND RECEIPTS
Bill No. Amount Paid

5. Date Treatment Done Medication
s
Signature

6. ENDODONTIC CASE RECORD

7. Pt. Name: Date:
Tooth Number:
Access Cavity Preparation and Pup Extripation:
Bio-Mechanical Preparation:
Length determination:
Instruments used:
Irrigants used: H2O2 / Saline/NaOCl/Metrogyl/Chlorhexidine
Obturation:
Complete / Sectional
Mastercone size:
Sealer used:
Condensation technique: Lateral / Vertical / Thermal
Post Operative X-Ray:
Apical Seal:
Lateral Condensation:
Post Endodontic Restoration:
Post Operative Follow up:
Signature
RADIOGRAPHIC INTERPRETATION

8. No. of Teeth present:
Existing Restorations:
Rediographic pulp exposure:
Lamina dura:
Periapical rediolucency:
a. No of teeth involved
b. Size and Shape
c. Nature of radiolucency
Periodontal Status:
a. Periodontal space widening
b. Interdental bone loss
Name of root canal in the involved teeth:
a. No. of canal
b. Shape
c. Anatomical variations
d. Patency
e. Presence of calcified structures, resorption, closure of apical portion
Previous endodontic treatment:
a. Status of root canal filling
b. Status of retrograde filling
Fracture of teeth:
a. Crown
b. Root
Any other abnormalities: