Department of Periodontology
Name of Operator
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Serial No
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Date
MM
/
DD
/
YYYY
Patient Code No
Your answer
Patient Name
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Nationality
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Tribe
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Gender
Age
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Adress
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Phone No
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Occupation
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Marital status
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Pregnant / contraceptives
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Children
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Chief complain
write in steps 1.2.3
Your answer
History of present illness
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Treatment Done
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Past dental history
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Past Medical History : Rheumatic fever, Heart disease, hypertension, asthma, jaundice, diabetes, bleeding tendencies, allergy to drugs, convulsions, thyroid, others
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Smoking
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smokeless tabacco
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Other
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Oral hygiene habits
Your answer
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