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Dental examination note template
A structure for a new-patient or full routine examination: history, a complete soft and hard tissue check, periodontal screening, radiographs and a treatment plan. Use it as a checklist for what a thorough exam note should cover, then write your own findings under each heading.
PRESENTING COMPLAINT
Presenting Complaint:
Assisted by:
MEDICAL HISTORY
Medical History:
Allergies:
Medications:
PMS Updated:
SOCIAL HISTORY
Smoking:
Cigarettes per Day:
Years of Smoking:
Previous Cigarettes per Day:
Previous Years of Smoking:
Vaping:
Vaping Details:
Alcohol:
Stress:
DENTAL HISTORY
Toothbrushing:
Interdental Cleaning:
Diet:
Attendance:
EXTRAORAL EXAMINATION
Temporomandibular Joint:
Muscles of Mastication:
Lymph Nodes:
Salivary Glands:
Facial Symmetry:
Lips:
INTRAORAL: SOFT TISSUE
Mucosa:
Gingivae:
Tongue:
Palate:
Floor of Mouth:
Oropharynx:
INTRAORAL: HARD TISSUE
Dentition:
Restorations:
Missing Teeth:
Oral Hygiene:
Tooth Wear:
SCREENING & TESTS
Basic Periodontal Examination (BPE):
Basic Erosive Wear Examination (BEWE):
SPECIAL TESTS
Special Tests:
RADIOGRAPHS
Type:
Radiograph Status:
Justification:
Quality Grade:
Caries:
Bone Levels:
Other Findings:
DIAGNOSES
Diagnosis:
Periodontal Diagnosis:
Differential Diagnosis:
RISK ASSESSMENT
Caries Risk:
Periodontal Risk:
Tooth Surface Loss Risk:
Oral Cancer Risk:
OPTIONS & ALTERNATIVES
Options Discussed:
Estimate Discussed:
TREATMENT PLAN
Plan:
Prevention:
Next Examination:
GDC standard 4.1 expects a patient's clinical record to be made as the appointment happens, and to be accurate and complete.
How Assist helps
Assist fills this in for you.
Assist records the appointment and drafts a note in this structure for the dentist to review and sign off. It writes up what was said in the room, and you check every line before it goes in the record.
28 days free. No card required.
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