Form 70 Endodontic Examination Use Patient Barcode Label Given Name Surname DOB TEMP Clinician Name: Clinician ID: Supervisor Name: (if student clinician) Supervisor ID: Tooth/Teeth FDI No's: Date of examination: Reason for Referral or Attendance: Presenting Complaint: No pain Other problems: Pain: Commenced: Duration/course: Dull ache Throbbing Cold Biting Lingering – How long?: ___ mins Sharp pain Spontaneous Heat Pressure Wakes at night Worse lying down Any other stimulus General Notes and History: Past Pain History: None Pain: Commenced: Duration/course: Dull ache Throbbing Cold Biting Lingering – How long?: ___ mins Sharp pain Spontaneous Heat Pressure Woke at night Worse lying down Any other stimulus Endo started prior to referral – by whom: Previous Endo: Tooth: When: By whom: Retreat: When: By whom: Surgery: When: By whom: Gr 0, I, II, III Mobility | | | | | | | | | | | | | | | | | | Tender to Palpation | | | | | | | | | | | | | | | | | | Tender to Percussion | | | | | | | | | | | | | | | | | | Sensitivity { Heat | | | | | | | | | | | | | | | | | | | CO2 | | | | | | | | | | | | | | Electric | | | | | | | | | Tests | | | | | | | | | | | | | | | | | | 8 7 6 5 4 3 2 1 | | | | | | 1 2 3 4 5 6 7 8 | | | | | | | 8 7 6 5 4 3 2 1 | | | | | | 1 2 3 4 5 6 7 8 | | | | | | | Pulp { Electric | | | | | | | | | | | | | | | | | | Sensitivity { CO2 | | | | | | | | | | | | | | | | | | Tests { Heat | | | | | | | | | | | | | | | | | | Tender to Percussion | | | | | | | | | | | | | | | | | | Tender to Palpation | | | | | | | | | | | | | | | | | | Gr 0, I, II, III Mobility | | | | | | | | | | | | | | | | | | Form 70_Version 1/2012_page 1 of 2   Endodontic Examination - **Tooth/Teeth FDI No's:** - **Date of examination:** - **Reason for Referral or Attendance:** ### Presenting Complaint - No pain - Other problems: ### Pain - **Commenced:** - **Duration/course:** - Dull ache - Throbbing - Cold - Biting - Lingering – How long?: ___ mins - Sharp pain - Spontaneous - Heat - Pressure - Wakes at night - Worse lying down - Any other stimulus ### General Notes and History ### Past Pain History - None - **Commenced:** - **Duration/course:** - Dull ache - Throbbing - Cold - Biting - Lingering – How long?: ___ mins - Sharp pain - Spontaneous - Heat - Pressure - Woke at night - Worse lying down - Any other stimulus ### Previous Endodontic Treatment - **Endo started prior to referral – by whom:** - **Previous Endo:** Tooth: ___, When: ___, By whom: ___ - **Retreat:** When: ___, By whom: ___ - **Surgery:** When: ___, By whom: ___ ### Clinical Tests (Tooth Chart) | Gr 0, I, II, III Mobility | | | | | | | | | | | | | | | | | | | Tender to Palpation | | | | | | | | | | | | | | | | | | | Tender to Percussion | | | | | | | | | | | | | | | | | | | Sensitivity: Heat | | | | | | | | | | | | | | | | | | | | Sensitivity: CO2 | | | | | | | | | | | | | | | | | | | | Sensitivity: Electric | | | | | | | | | | | | | | | | | | 8 7 6 5 4 3 2 1 | | | | | | 1 2 3 4 5 6 7 8 8 7 6 5 4 3 2 1 | | | | | | 1 2 3 4 5 6 7 8 - Pulp Sensitivity Tests: Electric, CO2, Heat - Tender to Percussion - Tender to Palpation - Gr 0, I, II, III Mobility ### Patient and Clinician Information **Use Patient Barcode Label** - Given Name: - Surname: - DOB: - TEMP: **Clinician Name:** **Clinician ID:** **Supervisor Name:** (if student clinician) **Supervisor ID:** Clinical data table for Endodontic Examination. The table features columns labeled with tooth numbers (8 through 1) and rows for clinical tests including 'Gr 0, I, II, III Mobility', 'Tender to Palpation', 'Tender to Percussion', and 'Sensitivity Tests' (Heat, CO2, Electric). Second section of the clinical data table. It contains identical row labels for dental tests ('Pulp Sensitivity Tests', 'Mobility', etc.) and column headers for tooth numbering, allowing for separate recording of findings. **Form 70** **Endodontic Examination continuation** **Findings:** \[\ ] Discolouration of tooth: _______________ \[\ ] Draining sinus: _______________ Location \[\ ] Caries: _______________ Tooth and colour \[\ ] Restoration(s): _______________ Material, quality and surfaces **Fractures:** \[\ ] Restoration(s) \[\ ] Tooth: \[\ ] Crown and/or \[\ ] Root **Cracks (surfaces):** _______________ **Enamel infractions (surfaces):** _______________ **Swelling:** \[\ ] None \[\ ] Diffuse \[\ ] Localised Region: _________________ \[\ ] Hard \[\ ] Soft \[\ ] Fluctuant Tender: \[\ ] to palpate \[\ ] to pressure **Occlusion:** \[\ ] Traumatic occlusion (teeth): _______________ \[\ ] Tenderness of masticatory muscles (muscles): _______________ **Periodontal status:** Local: _______________ General: _______________ **Radiographic Report:** **Films viewed:** \[\ ] PA's: _______________ Date(s) \[\ ] BW's: _______________ Date(s) \[\ ] OPG: _______________ Date(s) **Diagnoses:** (1) ______________________ (2) ______________________ (3) ______________________ (4) ______________________ (5) ______________________ **Cause(s):** (1) ______________________ (2) ______________________ (3) ______________________ (4) ______________________ (5) ______________________ **Management Plan:** (1) ______________________ (2) ______________________ (3) ______________________ (4) ______________________ (5) ______________________ **Prognosis:** \[\ ] Reassess after treatment/review \[\ ] Good \[\ ] Fair \[\ ] Poor \[\ ] Hopeless (advise Exo) **Probable restoration required:** Any alternative restoration(s) possible? List type(s): ______________________ **Recommendations for other treatment:** (1) ______________________ (2) ______________________ (3) ______________________ (4) ______________________ (5) ______________________ **Other notes:** (1) ______________________ (2) ______________________ (3) ______________________ (4) ______________________ (5) ______________________ --- | **Clinician Signature:** | **Clinician ID:** | **Supervisor Signature:** | **Supervisor ID:** | |---|---|---|---| | | | *(If student clinician)* | | **Form 70_Version 1/2012_page 2 of 2**  Clinical Findings and Observations **Findings:** - [ ] Discolouration of tooth: _______________ - [ ] Draining sinus: _______________ Location - [ ] Caries: _______________ Tooth and colour - [ ] Restoration(s): _______________ Material, quality and surfaces **Fractures:** - [ ] Restoration(s) - [ ] Tooth: [ ] Crown and/or [ ] Root **Cracks (surfaces):** _______________ **Enamel infractions (surfaces):** _______________ ### Swelling - [ ] None - [ ] Diffuse - [ ] Localised - Region: _________________ - [ ] Hard - [ ] Soft - [ ] Fluctuant - Tender: [ ] to palpate [ ] to pressure ### Occlusion - [ ] Traumatic occlusion (teeth): _______________ - [ ] Tenderness of masticatory muscles (muscles): _______________ ### Periodontal Status - Local: _______________ General: _______________ ### Radiographic Report **Films viewed:** - [ ] PA's: _______________ Date(s) - [ ] BW's: _______________ Date(s) - [ ] OPG: _______________ Date(s) ### Diagnoses 1. ______________________ 2. ______________________ 3. ______________________ 4. ______________________ 5. ______________________ ### Cause(s) 1. ______________________ 2. ______________________ 3. ______________________ 4. ______________________ 5. ______________________ ### Management Plan 1. ______________________ 2. ______________________ 3. ______________________ 4. ______________________ 5. ______________________ ### Prognosis - [ ] Reassess after treatment/review - [ ] Good - [ ] Fair - [ ] Poor - [ ] Hopeless (advise Exo) ### Probable Restoration Required - Any alternative restoration(s) possible? List type(s): ______________________ ### Recommendations for Other Treatment 1. ______________________ 2. ______________________ 3. ______________________ 4. ______________________ 5. ______________________ ### Other Notes 1. ______________________ 2. ______________________ 3. ______________________ 4. ______________________ 5. ______________________ --- | **Clinician Signature:** | **Clinician ID:** | **Supervisor Signature:** | **Supervisor ID:** | |-------------------------|-------------------|---------------------------|-------------------| | | | *(If student clinician)* | | ### Structural Integrity and Swelling *(Content integrated under Clinical Findings and Observations above)* Clinical examination form for endodontic procedures. The document contains sections for 'Findings' (discolouration, caries, fractures), 'Radiographic Report', 'Diagnoses', 'Management Plan', and 'Prognosis'. It includes checkboxes for conditions like 'Draining sinus', 'Swelling', and 'Occlusion', along with blank lines for text descriptions of tooth status, radiographs viewed, and treatment plans. [^1]: Original PDF page 1: [[Form 70 - Endodontic Examination.pdf#page=1|Form 70 - Endodontic Examination, p.1]] [^2]: Original PDF page 2: [[Form 70 - Endodontic Examination.pdf#page=2|Form 70 - Endodontic Examination, p.2]]