Endodontics History Taking Form

Comprehensive Patient Assessment and Treatment Planning

Static HTML Version: This form collects data and displays it on screen. Use the "Print Form" button to create a physical copy, or "Generate Summary" to view all entered data.
Patient Information
BIODATA
Patient History
S. (SUBJECTIVE)
Clinical Examination
O. (OBJECTIVE)

Extraoral:

Intraoral:

Clinical Tests:

Tooth # Cold Heat EPT Percussion Palpation Mobility Bite Test Discoloration

Legend: Normal: N, No Response: 0, Mild: +, Moderate: ++, Severe: +++, Lingered: L, Delayed: D

Periodontal Examination:

MB B DB DL L ML Recession Furcation Bleeding on Probing

Radiographic Findings:

Clinical Assessment
A. (ASSESSMENT)

Diagnosis:

Treatment Plan
P. (PLAN)

📋 Patient Summary Report