2b) Comprehensive Dental Examination
Consent
Verbal Consent received to proceed with data acquisition and performing the comprehensive exam
A) Chief Concern
Chief Concern: N/A
B) Data Collection
Dentures/appliances (top): N/A
Dentures/appliances (bottom): N/A
C) Extra-oral Exam
Head/Neck
Maxillary sinus: WNL
Submandibular lymph nodes: WNL
Cervical lymph nodes: WNL
Thyroid: WNL
Skin: WNL
TMJ Health
Click/Pop (on opening or closing): WNL
Pain: WNL
Deviation: WNL
Clenching/Grinding: WNL
D) Intra-oral Exam
Floor of mouth: WNL
Sides of the tongue: WNL
Papillae of tongue: WNL
Buccal Mucosa: WNL
Oropharynx: WNL
Hard Palate: WNL
Soft Palate: WNL
Tori: N/A
Lips: WNL
Occlusal Exam
Dental Exam
E) Oral Habits
Smoking or tobacco use type: None
Smoking or tobacco use route: None
Coffee consumption: None
Wine consumption: None
Acidic food or drink consumption: None
Use of facial (tongue or lip) jewelry: None
F) Dental Care
G) General Risk Assessment
Oral Cancer Screen: WNL
Stage (Severity): N/A
Grade (Progression): N/A
I) Prognosis
H) Risks, Benefits, Alternatives
The following risks, benefits, and alternatives were discussed: The risks of not doing anything were also discussed
J) Consent for treatment
Foreseeable fees: Agreed
Free and informed consent of the patient or legal guardian: Verbal