Home
Dentures
Schedule Now
Senior Living and Community Services
Shelters & Community Services
Contact
About
Blog
✕
TREATMENT RECORD- BETA
PRE-OPERATIVE MEDICAL SCREENING & PLANNING
Dr Koerner Oral Surgery Course, KCI
PATIENT NAME:
AGE:
Patient Name
*
SELECT BELOW THE INSTRUCTOR AND DOCTOR/S PARTICIPATING IN THIS APPOINTMENT:
INSTRUCTING DENTISTS
Karl Koerner
Andrew Drollinger
Beck Schneider
Tiana Hall
Jordan Willetsen
PARTICPATING DENTISTS:
Stephen Hernandez
Julie Ho
Joseph Dinnerstein
Forrest Gearhart
Nishita Irukulla
VITALS
BLOOD PRESSURE
SYSTOLIC
/
DIASTOLIC
PULSE RATE
PR
O2
O2
TREATMENT PLANNING
ROUTINE EXTRACTIONS (2-15 & 18-31)
INDICATE ROUTINE EXTRACTIONS BELOW
2
9
18
25
3
10
19
26
4
11
20
27
5
12
21
28
6
13
22
29
7
14
23
30
8
15
24
31
SURGICAL EXTRACTIONS (2-15 & 18-31)
INDICATE SURGICAL EXTRACTIONS BELOW
2
9
18
25
3
10
19
26
4
11
20
27
5
12
21
28
6
13
22
29
7
14
23
30
8
15
24
31
3RD MOLAR 1, 16, 17, 32
TOOTH 1
TOOTH 1
ERUPTED
IMPACTED
ST
PB
CB
TOOTH 16
TOOTH 16
ERUPTED
IMPACTED
ST
PB
CB
TOOTH 17
TOOTH 17
ERUPTED
IMPACTED
ST
PB
CB
TOOTH 32
TOOTH 32
ERUPTED
IMPACTED
ST
PB
CB
OTHER PROCEDURES RECOMMENDED
OTHER PROCEDURES
AVEOPLASTY
TORUS
EXOSTOSES
FRENECTOMY
EPULIS
BONE GRAFT
ALVEOPLASTY
INDICATE ALVEOPASTY TOOTH # BELOW
2
9
18
25
3
10
19
26
4
11
20
27
5
12
21
28
6
13
22
29
7
14
23
30
8
15
24
31
TORUS
HOW MANY TORI WERE REMOVED?
1
2
3
4
5
6
EXOSTOSES
HOW MANY EXOSTOSES WERE REMOVED?
1
2
3
4
5
6
FRENECTOMY
WAS A FRENECTOMY PREFORMED?
YES
EPULIS
BONE GRAFT
HOW MANY BONE GRAFTS WERE PERFORMED?
1
2
3
4
5
6
7
8
ADDITIONAL NOTES
INIDCATE THE PARTICPATING DENTIST WHO PREFORMED THE ABOVE PROCEDURES:
Submit
Δ
Loading Comments...
Write a Comment...
Email (Required)
Name (Required)
Website
