Clinical Notes Interview and Exam Notes Name First Last DateChief Concern Check up Cleaning Consult Pain and Discomfort Lost Filling/Crown Wisdom tooth TMJ problem Other Concerns: HistoryWisdom teeth condition/state? Existing Extracted/Missing Not Sure Orthodontics? Never had Had before, No reatiner Had before, Has Retainer TMJ? Normal Occasional Pain and Discomfort Not Sure Habits Clench/Grind Nail Biting Other Trauma Yes No Last Dental visit?Additional Notes: Clinical ExamExtra Oral Exam( select if WNL) Head Neck Skin Lymph Nodes TMJ -Right Side WNL Popping/Clicking Pain Limited Opening TMJ -Left Side WNL Popping/Clicking Pain Limited Opening Existing Conditions?Occlusion-RightClass IClass IIClass IIIOcclusion-LeftClass IClass IIClass IIICross Bite Right Left Front Over jet-2-1012345678910>10Over BiteOpen Bite 1Open Bite 2Open Bite >2010%20%30%40%50%60%70%80%90%100%MaxilaMild CrowdingModerate CrowdingSevere CrowdingGeneralized SpacingDiastemaMandibleMild CrowdingModerate CrowdingSevere CrowdingGeneralized SpacingIntra Oral Exam ( select if WNL) Lips Buccal Mucosa Floor of the mouth Soft and Hard Palate Pharynx and Tonsils Tongue Existing Conditions?Periodontal AssesmentGingiva WNL Edematous Ulcerated Recession Generalized Localized Biofilm Index WNL Mild Moderate Heavy Generalized Localized Stain WNL Mild Moderate Heavy Generalized Localized Calculus WNL Mild Moderate Heavy Generalized Localized Existing ConditionMissing teeth 18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 38 37 36 35 34 33 32 31 41 42 43 44 45 46 47 48 List Treatment Options Night Gurad Hygiene Implant Extraction Crown Root Canal Gum Graft Observe Bone Graft/Sinus Lift Ortho Other List Notes