Dental Consultation & Examination

Chairside patient evaluation, subjective complaints, objective clinical testing, and diagnostic care planning.

Dental Chart

Patient Name

PT-00000 Consultation Active

Age: 34 yrs • Gender: Female • Blood Group: O+ • Phone: +1 555 0142 • Email: sophia.m@example.com

Blood Pressure 122/78 mmHg

Heart Rate 74 bpm

Respiration 16 /min

Temperature 98.6 °F

Consultation Details

Encounter record: CS-2026-0842

Comprehensive Evaluation

Attending Dentist

Dr. Emily Carter

General Dentistry

Date & Time

2026-10-15

09:30 AM

Operatory Chair

Room 1 - Chair 1

Dental Suite A

Chief Complaint & History of Illness

Patient Chief Complaint (Subjective) *

Pain Scale (VAS) 8 / 10

0 (None) 5 (Mod) 10 (Severe)

Symptom Duration

Diagnostic Radiograph

Tooth #36 Focus

Apical Radiolucency #36 2026-10-15

70 kVp 12 mAs 98.4% AI Caries Match

Mandibular molar apex indicates widened periodontal ligament space consistent with pulpitis.

View PACS

Soft Tissue & TMJ Findings

Extraoral (TMJ, Lymph Nodes, Facial Symmetry)

Intraoral Mucosa (Gingiva, Tongue, Palate)

Tooth-Specific Observations & Diagnostic Tests

FDI 2-Digit

Objective endodontic vitality, percussion, palpation, and mobility evaluations across inspected dentition.

3D Dental Chart Perio Probing

Tooth (FDI & Quadrant)	Clinical Findings & Observations	Percussion Test	Palpation Test	Thermal Vitality	Mobility Grade	Action

Positive: Pathologic response / pain Negative: Physiological healthy response Non-responsive: Non-vital or pulp canal obliteration

Standard ISO 3950 Dental Testing Protocol

Diagnosis & Recommended Care Plan

ICD-10 Coded

Primary Dental Diagnosis *

Secondary Diagnosis / Co-morbidity

Recommended Clinical Procedures

CDT Dental Codes

Dentist Impressions & Informed Consent

Clinical Rationale, Patient Counseling & Procedural Agreement

Prescriptions & Pharmacy

All Rx →

Past Consultations

This patient

Encounter Actions

Status: In Progress Auto-saved to local browser