Department of conservative dentistry
Student name
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Student logbook No
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Date
MM
/
DD
/
YYYY
Patient personal data :
Patient Code No
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Patient Name
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Age
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Nationality
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Tribe
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Gender
Address
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Telephone No
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Occupation
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Chief complain
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History of present complains
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Pain history :
1.How long have you had the pain
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2.Location
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3.Onset
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4.Duration
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5.Quality
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6.Aggravating factor
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7.Relieving factor
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Medical history
Other conditions
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Social history :
Family medical history
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Smoking
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Snuffing
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Alcohol consumption
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Coffee / tea
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Oral hygiene attitude
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Past dental history :
Previous dental treatment
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Complication
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