Description: Set printer on highest resolution.

Name: ___________________________________________ Date: _________________

Each dot on tooth root represents 2mm recession.

Sonicare: Recommended Dispensed Using
Fluoride: Recommended Dispensed Using
OH: E G F P

Medical Alerts:

Clinical/X-ray Findings
1
2
3
4/A
5/B
6/C
7/D
8/E
9/F
10/G
11/H
12/I
13/J
14
15
16
17
18
19
20/K
21/L
22/M
23/N
24/O
25/P
26/Q
27/R
28/S
29/T
30
31
32

Periodontal Disease Diagnosis:
___Healthy periodontium
___Gingivitis, localized / generalized
___Chronic Periodontitis, localized / generalized
slight / moderate / severe
___Aggressive Periodontitis, localized / generalized
slight / moderate / severe
___Other:
_________________________________________________________
Maximum Inter-incisal Opening: ____mm
Midline: Max is ___mm to the R / L of Mand
Overbite: ___mm or ___%; Overjet:___mm or ___%
Orthodontics:______________________________
Recall Rx: 3 4 6 9 12
o by pt. request

Appt 1:	Time
Appt 2:
Appt 3:
Appt 4:
Appt 5:
Notes for next recall: / Next x-rays: