DENTAL CHARTING CHECKLIST TEMPLATE

Created by ChecklistGuro (https://checklistguro.com)


--- PATIENT DEMOGRAPHICS VERIFICATION ---
[ ] Patient First Name
[ ] Patient Last Name
[ ] Date of Birth
[ ] Patient Phone Number
[ ] Insurance Provider (Aetna, Cigna, Delta Dental, Blue Cross Blue Shield, Other)
[ ] Gender (Male, Female, Other)

--- CHIEF COMPLAINT & HISTORY ---
[ ] Chief Complaint (Patient's Words)
[ ] Detailed History of Presenting Complaint
[ ] Duration of Complaint (Days/Weeks)
[ ] Relevant Medical History (Diabetes, Hypertension, Heart Disease, Allergies, Medications, Other (Specify))
[ ] Medications (List and Dosage)
[ ] Date of Last Dental Visit
[ ] Reason for Visit (Routine Checkup, Emergency, Restoration, Cleaning, Other)

--- EXTRAORAL EXAMINATION ---
[ ] Patient Name
[ ] Chief Complaint (Extraoral Perspective)
[ ] TMJ Assessment (Left) (Normal, Clicking, Popping, Crepitus, Pain, Limited ROM)
[ ] TMJ Assessment (Right) (Normal, Clicking, Popping, Crepitus, Pain, Limited ROM)
[ ] Neck Circumference (cm)
[ ] Observations - Skin/Lymph Nodes

--- INTRAORAL EXAMINATION - SOFT TISSUES ---
[ ] Lip Condition (Color, Texture, Lesions)
[ ] Cheek Condition (Color, Texture, Lesions)
[ ] Tongue Condition (Color, Papillae, Ulcerations)
[ ] Floor of Mouth Condition (Color, Masses, Lesions)
[ ] Palate Condition (Color, Texture, Lesions)
[ ] Presence of Ulcerations? (Yes, No, Uncertain)
[ ] Saliva Characteristics (Quantity, Consistency, Color)

--- INTRAORAL EXAMINATION - HARD TISSUES ---
[ ] Tooth #
[ ] Enamel Condition (Normal, Hypomineralization, Demineralization, Attrition, Abrasion, Erosion)
[ ] Dentin Condition (Normal, Sensitivity, Discoloration)
[ ] Crown/Restoration Condition (if applicable) (Intact, Loose, Fractured, Decemented, Secondary Caries)
[ ] Notes on Tooth Condition
[ ] Existing Caries Depth (mm)

--- PERIODONTAL ASSESSMENT ---
[ ] Probing Depth (Anterior)
[ ] Probing Depth (Posterior)
[ ] Recession (mm)
[ ] Bleeding on Probing (BOP) (Yes, No)
[ ] Mobility (mm) (0, 1, 2, 3)
[ ] Furcation Involvement (Class I, Class II, Class III, Class IV, None)
[ ] Additional Periodontal Notes

--- CARIES ASSESSMENT (TOOTH SURFACES) ---
[ ] Tooth Surface D1 (Occlusal): (Sound, Small Caries, Moderate Caries, Extensive Caries, N/A)
[ ] Tooth Surface D2 (Mesial-Occlusal): (Sound, Small Caries, Moderate Caries, Extensive Caries, N/A)
[ ] Tooth Surface D3 (Distal-Occlusal): (Sound, Small Caries, Moderate Caries, Extensive Caries, N/A)
[ ] D1 Caries Depth (mm):
[ ] D2 Caries Depth (mm):
[ ] D3 Caries Depth (mm):
[ ] Existing Restoration on Surface D1: (Amalgam, Composite, Gold, Crown, None)

--- RESTORATIONS & EXISTING DENTAL WORK ---
[ ] Tooth Number
[ ] Restoration Type (Amalgam, Composite, Crown (Porcelain/Zirconia), Inlay/Onlay, Gold, Other)
[ ] Size/Width (mm)
[ ] Condition (Excellent, Good, Fair, Poor)
[ ] Notes/Comments
[ ] Placement Date
[ ] Lab/Manufacturer

--- OCCLUSION & BITE ANALYSIS ---
[ ] Occlusal Class (Class I, Class II (Distal Occlusion), Class III (Mesial Occlusion))
[ ] Overbite (mm)
[ ] Overjet (mm)
[ ] Occlusal Interferences/Premature Contacts
[ ] TMJ Status (Normal, Clicking, Popping, Pain/Limited ROM)
[ ] Deviations/Comments (e.g. Crossbite, Open Bite)

--- RADIOGRAPHIC ASSESSMENT ---
[ ] Radiograph Type(s) Taken (Bitewing, Periapical, Panoramic, Full Mouth Series, Cone Beam CT (CBCT), Other (Specify in Long Text))
[ ] Radiographic Findings (Detailed)
[ ] Radiograph Date (MM/DD/YYYY)
[ ] Attach Radiograph Image(s)
[ ] Radiographic Assessment Quality (Excellent, Good, Fair, Poor)

--- TREATMENT PLAN RECOMMENDATIONS ---
[ ] Prioritized Treatment Categories (Restorative, Preventative, Periodontal, Endodontic, Orthodontic, Cosmetic)
[ ] Estimated Treatment Cost
[ ] Proposed Treatment Start Date
[ ] Patient Communication Notes (e.g., financial arrangements, treatment explanation)
[ ] Financial Arrangement Type (Cash, Insurance, Payment Plan)
[ ] Treatment Sequencing Priority (High, Medium, Low)
[ ] Additional Notes / Considerations

--- END OF TEMPLATE ---
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