RFV (Reason For Visit)
In the patient’s own words. “Why did you come to see us today?”
HPC (History of Presenting Complaint)
If applicable
MH (Medical History) First go over medical questionnaire with client.
| “Are you taking any medicines or drugs?” Look for prescribed, pharmacy, supplements, social drugs | Drug related questions (4) |
| “Have you ever smoked? | |
| “Do you drink alcohol or take any social drugs?” | |
| “Have you ever had any allergies?” Penicillin especially |
| “Have you ever been admitted to hospital for an operation?” | Operations and cardiorespiratory (4) |
| “Have you ever had any problems with your heart?” Blood pressure too. | |
| “Have you ever had any problems with bleeding?” | |
| “Have you ever had any problems with your chest or with breathing?” Asthma and infections. |
| “Are you pregnant?” | Miscellaneous (2) |
| “Are you fit and well?” |
DH and SH (Dental History and Social History)
| “How often do you go to the dentist?” | At the dentist (5) |
| “When was the last time you went to the dentist and what did the dentist do?” | |
| “What types of dental treatment have you had previously?” Identifying problems with GA or LA and finding out what has been done before – orthodontics, periodontics, root canal… | |
| “How do you feel about dental treatment?” | |
| “What do you think about the appearance of your teeth?” |
| “How do you take care of your teeth?” | Brushing and flossing (3) |
| “How often do you brush your teeth and how long for?” | |
| “How often do you floss?” |
| “Have you ever had any pain or clicking from your jaw joints?” | Bruxing (2) |
| “Do you grind your teeth or bite your nails?” |
| “Can you tell me what you’d typically have for breakfast…lunch…dinner? | Diet (3) |
| “What are your favourite foods?” | |
| “What are your favourite drinks?” |
| “What do you do?” SES | Miscellaneous (2) |
| “Where do you live?” Fluoride and traveling distance/time |
EO (Extra Oral Examination)
Head and face appearance – symmetry, colour, swellings.
Eyes – colour
TMJ – feel for clicking, locking or crepitus. Also feel muscles of mastication for tenderness.
Neck – palpate from behind starting under chin.
IO (Intra Oral Examination)
Oropharynx and tonsils.
Inspect entire oral mucosa.
Examine teeth for caries and quality of any restorations. Chart teeth present.
Occlusion – relationship between arches. Prematurities and displacements seen during closure?
CPITN.
Oral hygiene.
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