Inland Empire Perio Study Club - presentation date- - Name of Study Club Member - - Patient ID -

Facial Photo + Patients Background

Medical History Item 1 Item 2 Item 3 Item 4 Item 5 Item 6 Item 7

Chief Complaint Complaint 1 Complaint 2 Complaint 3

Dental History DentHx1 DentHx2 DentHx3 DentHx4 DentHx5 DentHx6 DentHx7

Family History FamilyHX1 FamilyHX2 FamilyHX3 FamilyHX4

Dental Findings DentalFinding1 DentalFinding2 DentalFinding3 DentalFinding4 DentalFinding5 DentalFinding6 DentalFinding7 DentalFinding8

Dental Findings, 2 nd slide if needed DentalFinding1 DentalFinding2 DentalFinding3 DentalFinding4 DentalFinding5 DentalFinding6 DentalFinding7 DentalFinding8

Periodontal Findings PerioFinding

Radiographic Findings XrayFinding

Facial Photo /Frontal intraoral photo (full arch, occluding)

Facial Photo (normal smile) /Facial Photo (exaggerated smile)

Facial Photo (lips relaxed) /Profile Photo

Maxillary Arch, occlusal photo /Mandibular Arch, occlusal photo

R Posterior photo, in occlusion /L Posterior photo, in occlusion

Probings, maxillary /Probings, mandibular

X-rays, right half /X-rays, left half

UR Posterior, buccal photo /UR Posterior, lingual photo

Probings, UR Posterior /X-rays, UR Posterior

Probings, U Anterior /X-rays, U Anterior

UL Posterior, lingual photo /UL Posterior, buccal photo

Probings, UL Posterior /X-rays, UL Posterior

LL Posterior, lingual photo /LL Posterior, buccal photo

L Anterior, facial photo /L Anterior, lingual photo

Probings, Lower Anterior /X-rays, Lower Anterior

Probings, upper /Probings, lower

X-rays, right /X-rays, left

Diagnoses Diagnosis1 diagnosis2 diagnosis3 diagnosis4 diagnosis5 diagnosis6 diagnosis7

Diagnoses, 2 nd slide if needed Diagnosis1 diagnosis2 diagnosis3 diagnosis4 diagnosis5 diagnosis6 diagnosis7

Problem List Problem 1 Problem 2 Problem 3 Problem 4 Problem 5 Problem 6 Problem 7

Problem List, 2 nd slide if needed Problem 1 Problem 2 Problem 3 Problem 4 Problem 5 Problem 6 Problem 7

Etiology and Contributing Factors Item 1 Item 2 Item 3 Item 4 Item 5 Item 6 Item 7 Item 8

Etiology and Contributing Factors 2 nd slide if needed Item 1 Item 2 Item 3 Item 4 Item 5 Item 6 Item 7 Item 8

Prognosis, Short Term Excellent: Good: Fair: Poor:

Prognosis, Long Term Excellent: Good: Fair: Poor:

PAUSE HERE for Discussion

Treatment Options Proposed to patient Item 1 Item 2 Item 3 Item 4 Item 5 Item 6 Item 7 Item 8

Treatment Options Proposed to patient, slide 2 Item 9 Item 10 Item 11 Item 12 Item 13 Item 14 Item 15 Item 16

Treatment Options accepted by patient Item 1 Item 2 Item 3 Item 4 Item 5 Item 6 Item 7 Item 8

Treatment Options accepted by patient Item 9 Item 10 Item 11 Item 12 Item 13 Item 14 Item 15 Item 16

Post-Treatment Photos (if available)

THE END