PROFORMA
- Name
- Age
- Sex
- Address
- Attendant's name
- Relationship of attendant with patient
- Occupation of father
- Occupation of mother
- Occupation of guardian (if any)
- Present physician's name and address
CHIEF COMPLAINT (In patient's/attendant's words)
HISTORY
- Parental history
- Prenatal history
- Natal history
- Postnatal and infancy history
I. PARENTAL HISTORY
- Any prosthesis worn
- Discoloration of teeth
- Soft teeth
- Wearing down of teeth
II. PRENATAL HISTORY (Asked to mother of patient)
-
- Duration
- Treatment taken
- Diet pattern during pregnancy
- Any blood incompatibility between mother and child
- Fluoride intake during pregnancy
- Rh-factor and blood group
- Any systemic/debilitating disease
- Duration
- Treatment taken
III. NATAL HISTORY
- Premature birth
- Jaundiced at birth
- History of blood transfusion
- ‘Blue’ baby/cyanosed baby
IV. POSTNATAL AND INFANCY HISTORY
Medical history of
- Convulsions
- Breastfeeding-duration
- Bottle-feeding-duration
- Fluoride intake
- Vitamin/mineral/water supplements
- Duration
- Form of supplements
- Rheumatic fever
- Congenital hematological disorders
- Kidney diseases
- Skeletal deformities (Broken bones/joint pain)
- Frequency
- Duration
- Treatment taken
- Walking habits
- Eating habits
- Mental/physical disabilities
- Any antibiotic treatment
- When
- Duration of treatment
- Any surgical intervention
- Reason
- Surgeon's name and address
- Duration of treatment
- Attitude towards environment/friends
- Any other childhood diseases- specify details
- Allergic history
- Foods
- Local anesthetics
- Penicillin/other antibiotics
- Others
Dental history of
- Toothaches
- Bleeding gums
- Trauma
- Dental caries
- Developmental disturbances of dental significance
- Attitude towards dentists
- Poor oral hygiene
- Mouth cleaning habits
GENERAL EXAMINATION
- Stature
- Height
- Weight
- Gait
- Unsteady weakness gaits
- Waddling gaits
- Equinus gaits
- Scissors gaits
- Hemiplegic gaits
- Steppage gaits
- Shuffling gaits
- Wobbling gaits
- Staggering gaits
- Ataxic gaits
- Hands
- Temperature
- Skin moisture
- Skin dryness/wrinkles
- Speech
- Aphasia
- Delayed speech
- Stuttering
- Articulatory disorders
- Cluttering
- Stammering
- Skin lesions
- Scales
- Macules
- Crusts
- Vesicles
- Ulcers
- Growth of fingers
- Nails
- Bitten
- Spoon-shaped
- Pitted
- Brittle
- Scaly
- Thickened
- Covered with skin
- Discolored
- Absent
EXAMINATION OF HEAD AND NECK
- Size and shape of head
- Macrocephaly
- Microcephaly
- Abnormal head shapes
- Hair and skin
- Alopecia
- Skin lesions
- Temporomandibular joint
- Limitation of movement
- Subluxation
- Dislocation
- Mandibular deviation
- Trismus
- Ears
- Pain
- Discharge (if any)
- Eyes
- Vision
- Action of eyelids
- Inflammation
- Swelling/puffiness around eye
- Crusting/lesions on eyelids
- Conjunctivitis
- Iris defect
- Abnormal lacrimation
- Nose
- Size
- Shape
- Color
- Neck
- Skin
- Symmetry
- Lymphadenopathy
- Tenderness/enlargement of glands
- Facial swelling and asymmetry
EXAMINATION OF ORAL CAVITY
- Breath
- Pleasant
- Halitosis
- Acetonic odor
- Lips
- Size
- Shape
- Color
- Surface texture
- Buccal mucosa
- Stenson's duct papilla-inflamed ‘or’ not
- Swelling in cheek
- Lesions
- Color
- Surface
- Other findings(if any)
- Saliva
- Quantity
- Quality
- Thin
- Normal
- Viscous
- Gingiva
- Color
- Form
- Pain/tenderness
- Labial frenula
- Inflammation
- Spontaneity of bleeding
- Tongue
- Size
- Shape
- Color
- Any ulceration
- Surface
- Dryness
- Undersurface of tongue
- Palate
- Symmetry
- Color
- Presence of lesions/deformity/scar
- Pharynx and tonsils
- Teeth
- Anodontia
- Supernumerary teeth
- Macrodontia
- Microdontia
- Staining
- Calculus deposits
- Hypocalcification
- Physical injuries
- Caries
- Hypoplasia
- Dilaceration
- Dwarfism
- Gemination
- Fusion
- Notched teeth
- Peg-shaped teeth
- Malocclusion status
- Class I
- Class II (div1/2/subdiv)
INVESTIGATIVE METHODS
- Radiographs
- IOPA
- Orthopentomograph
- Bite-wing
- Cephalogram
- Biopsy
- Pulp testing
- CADIA
TREATMENT PLANNING
- Medical treatment
- Referral to physician
- Systemic treatment
- Premedication
- Therapy for oral infection
- Preparatory treatment
- Oral prophylaxis
- Caries control
- Oral surgery
- Orthodontic consultation
- Endodontic therapy
- Corrective treatment
- Operative dentistry
- Prosthetic dentistry
- Orthodontic dentistry
- Periodic recall examination and maintenance treatment