Emergency Exam

FRONT DESK: Appt Date ______Time ______Phone ______Provider ______

Patient's name ______Weight (if under age of 14 only) ______Date ____\_____\____

Chief complaint and history ______

  1. Is one of your teeth broken or have a hole in it ______
  2. Is there any swelling ______
  3. When did you first notice the problem ______
  4. Are you having pain? For how long? ______
  5. Is pain sharp or dull, continuous or throbbing ______
  6. Do you know which tooth ______
  7. What makes tooth hurt: hot, cold, bite Do you have any sensitivity to biting pressure Yes / No
  8. If patient is new, ask "How did you find out about our office"______
  9. How soon do you want treatment done, and why? ______

TESTS: ASSISTANT / CAMERA

Swelling yes/no Looseness of the tooth yes/no Taking any pain medication yes/no Fistulous tract – yes/no Lymph nodes tender - yes/no Sharpness to tongue yes/no

Fever - yes/no Filling out how long ______Decay - yes/no

Date
Tooth #
Ice / Normal
No Response
Pain-went away quickly
Pain Lingered / Normal
No Response
Pain-went away quickly
Pain Lingered / Normal
No Response
Pain-went away quickly
Pain Lingered / Normal
No Response
Pain-went away quickly
Pain Lingered / Normal
No Response
Pain-went away quickly
Pain Lingered / Normal
No Response
Pain-went away quickly
Pain Lingered / Normal
No Response
Pain-went away quickly
Pain Lingered / Normal
No Response
Pain-went away quickly
Pain Lingered
Elec.
Test
Percussion / + - / + - / + - / + - / + - / + - / + - / + -
Palpation / + - / + - / + - / + - / + - / + - / + - / + -
Tooth Sleuth

Do you want to keep your natural teeth for a lifetime? Yes / No

Options: ______

Treatment Plan: ______

Medications Given:______Assistant ______

Response to insurance: ”We are considered out of network on your plan, if this is allowed, we can help you.”

I. Date ______

Amoxicillin 500 mg / 21 tabs (2 stat, 1 tid) ______

Zithromax dispense Z pack – (less GI upset) (If allergic to Amoxicillin)______

3-200mg Ibuprofen(600mg)or2 Ibuprofen(400mg) + 2 regular strength Tylenol 700mgQ6h______

Medrol dose pack - as directed ______

Clindamycin 150mg 56 caps (if allergic to amoxicillin)

II. Day 2 ______on meds and still significant symptoms

Metronidazole (Flagyl) with Amox or Clindamycin______

Vicodin 10 tabs – 2 stat then 1 or 2 q 4h prn pain ______

(significant swelling – refer to oral surgeon)

III. Children Day 2

Amoxi (Amoxicillin) 40mg/2 lbs, TID for 7 days

Cleocin (clindamycin) – 20mg/2lbs, TID for 7 days

IV. Day3 if no change ______

Refer for management and culture

Date ______ ENDO TREATMENT

Tooth # Canals _____Can__ Canals
Dx File Length & #
Reference Point
Working Length
Final File #
Gates Glidden
Tooth # Canals Can______CanalsaCanCansla
Dx File Length & #
Reference Point
Working Length
Final File #
Gates Glidden

Anesthesia Y N N20___ Rubber Dam___ Xrays___ Marcaine ___ Open___ Pt___ Temp Seal___

Ibuprofen/Tylenol______Medrol 4 mg: 10 tabs_____(1 q.i.d.) Vicodin______Amox 500 mg: 20 tabs______(1 q.i.d.)

Clindamycin 150 mg: 40 capsules______(2 q.i.d.)

Comments ______

Date ______ SEAL

Rubber Dam___ Xray___ Anes___ N20___ Marcaine___ Fill Grossman's___ GP___

Oil of Eucalyptol___ if wait on crown – shorten posterior teeth 1mm and place core

Amox 500 mg: 20 tabs___, Clindamycin 150 mg: 40 capsules___ Medrol 4 mg: 10 tabs___

(1 t.i.d.) (2 q.i.d.) (1 q.i.d.)

Comments ______