DATA REKAM MEDIK PENDERITA

I. DATA PRIBADI

Nama

:Alamat

:Telepon

:Tanggal Lahir

:Jenis Kelamin

:Tinggi Badan

:

Berat Badan

:

Pekerjaan

:Status Pernikahan

:

Kerabat Terdekat

:II. RIWAYAT DENTAL1. Keluhan Utama

: ................................................................................

.................................................................................................................................. 2.Riwayat Penyakit Sekarang: ................................................................................

..................................................................................................................................3.Riwayat Dental yang Lalu: ................................................................................

..................................................................................................................................III. PEMERIKSAAN UMUM1. PEMERIKSAAN EKSTRA ORAL *

a. Kepala dan Leher

Kepala

: ............................................................................................Gld. Thyroid

: ............................................................................................

V. Jugularis

: ............................................................................................

Wajah-leher

: ............................................................................................

b. Kelenjar Limfe

- Submandibularis Sin: ........................................................................................................

Dext: ........................................................................................................- Submentalis: ............................................................................................- Cervicalis

: ............................................................................................2. PEMERIKSAAN INTRA ORAL *

a. Rongga Mulut

Bibir

: ............................................................................................Buccal mucosa: ............................................................................................

Lidah

: ............................................................................................

Dasar mulut

: ............................................................................................

Palat. Durum

: ............................................................................................

Palat. Molle

: ............................................................................................

Tonsil

: ............................................................................................

Oropharynx

: ............................................................................................

Calculus

Maxilla: Ant regio

.....................................................................Post regio

..................................................................... Mandibula: Ant regio.....................................................................Post regio.....................................................................

b. Gingiva

Maxilla: Ant regio

.....................................................................Post regio

..................................................................... Mandibula: Ant regio.....................................................................Post regio.....................................................................IV. STATUS INTRA ORAL PEMERIKSAAN GIGI-GIGI DAN JARINGAN LUNAKElemen

: ................................................................................

Caries (lokasi dan kedalaman): ................................................................................

Tes dingin

: ................................................................................

Tes panas

: ................................................................................

EPT

: ................................................................................

Perkusi

: ................................................................................

Druk

: ................................................................................

Sordes dan calculus

: ................................................................................

Kemerahan

: ................................................................................

Oedematous

: ................................................................................

Mudah berdarah

: ................................................................................

Resesi gingiva

: ................................................................................

Goyang

: ................................................................................

Pocket (lokasi dan kedalaman): ................................................................................V. PEMERIKSAAN PENUNJANG

Interpretasi:

........

............................NB: untuk pengisian STATUS INTRA ORAL PEMERIKSAAN GIGI-GIGI DAN JARINGAN LUNAK gunakan tanda dibawah ini:

( 0 ) = tidak dilakukan pemeriksaan

( + ) = dilakukan pemeriksaan, ada keluhan

( - ) = dilakukan pemeriksaan, tidak ada keluhanPAGE 4