1-Do you know for sure which tooth is the problem?  ______________________

 

2-For how long has this been a problem?  _______________________________

 

3-Is the problem getting worse, better, or staying about the same?  __________

 

4-Has this tooth or area had dental work done in the past 3 months?  _________

 

5-What, if anything, causes the pain to increase (such as hot, cold, chewing..)?

 

________________________________________________________________

 

6-Does the tooth ever hurt “for no reason”-without any of the above happening?

 

________________________________________________________________

 

7-Do you have any swelling or tenderness in the face or gums near this area?

 

___________________________________________________________

 

8-Have you ever had an accident or received a blow to this area, even many years ago? ___________________________________________________

 

 

DENTAL EXAM

 

1-ENDO THERAPY HAS BEEN INITIATED         c YES                     c NO                    c UNKNOWN / NOT EXAMINED

 

2-DEEP DECAY CLINICALLY OR ON XRAY        c YES                     c NO                    c UNKNOWN

 

3-ACTUAL PULP EXPOSURE HAS OCCURRED   c  YES                     c NO                   c  UNKNOWN

 

4-VERY DEEP RESTORATION ON TOOTH        c YES                      c NO                   c UNKNOWN

 

5-PERIAPICAL PATHOLOGY ON FILM              c YES                      c NO                   c UNKNOWN

 

6-SWELLING OR FISTULA PRESENT                c YES                      c NO                  c UNKNOWN

 

7- PERCUSSION POSITIVE                             c YES                      c NO                  c UNKNOWN

 

8-PALPATION POSTITVE                                c YES                      c NO                  c UNKNOWN

 

9-MOBILITY PRESENT                                    c YES                     c NO                  c UNKNOWN

 

10-DEEP PERIO POCKET                                c YES                      c NO                  c UNKNOWN

 

11-ICE TEST(MID-BUCCAL) POSITIVE              c YES                     c NO                  c UNKNOWN

 

12-BITE STICK POSITIVE                               c YES                      c NO                  c UNKNOWN