2021 Adult Hygiene

Last Recall Date: [AUTO: Last Recall Date]

DENTIST: [SELECT/INSERT: Dentists]
RDH: [SELECT/INSERT: Hygienist]
RDA: [SELECT/INSERT: RDA]

Checked Cl 5 Indicators on all cassettes used for procedure as well as indicators on bagged instruments: [SELECT/INSERT: Cl5 Indicator Strip Checked]

Miele Sterilization Codes Scanned:

Informed verbal consent given by [AUTO: Patient First Name] [AUTO: Patient Last Name] [SELECT/INSERT: CONSENT FOR TX] for treatment today.
Medical history reviewed: [SELECT/INSERT: MedHx/DentalHx]
Premedication Required: [SELECT/INSERT: PREMED]


Patient Chief Concern: [SELECT/INSERT: PATIENT CC]

Hygiene Area of Concern:

Plaque:  [SELECT/INSERT: PLAQUE]
Stain:  [SELECT/INSERT: STAIN]
Calculus: [SELECT/INSERT: CALCULUS]
Bleeding: [SELECT/INSERT: BLEEDING]

PSR/Pocketing:  _ _ _ / _ _ _
Recession:
FMP Done: [SELECT/INSERT: FMP DONE]

Health/Gingivitis: [SELECT/INSERT: HEALTH]

Periodontitis Stage:            [SELECT/INSERT: PERIODONTITIS: STAGING]
Periodontitis Grade: [SELECT/INSERT: PERIODONTITIS: GRADING]

Oral hygiene compliance: [SELECT/INSERT: OHI COMPLIANCE]
Home care instruction: STRESSED THE IMPORTANCE OF HOMECARE- IDEALLY FLOSSING AT LEAST 1XDAY AND BRUSHING MINIMUM 2XDAY
OH Aids Reviewed/Recommended: [SELECT/INSERT: OHI AIDS REVIEWED/RECOMMENDED]

REVIEWED DISEASE PROCESS WITH PATIENT TODAY

Patient is currently: [SELECT/INSERT: FLOSSING x/day] [SELECT/INSERT: BRUSHING x/day]


Hygiene goal:


Treatment recommended:
1) HYGIENE MAINTENANCE


Treatment completed today: [SELECT/INSERT: RDH: Treatment]

Anesthetic:  [SELECT/INSERT: HYGIENE ANESTHETIC]

Desensitizer: [SELECT/INSERT: DESENSITIZER]

Does patient have a NightGuard?
Do they use NightGuard?

Have they had orthodontics?
Do they wear Retainers? Fixed or removable?
Additional Notes:
-ALL PROPER PPE WAS WORN DURING APPT AS PER AHS AND CRDHA GUIDELINES
Recommended Recall Interval:[SELECT/INSERT: REC RECALL INTERVAL]
Recommended Hygiene Interval: [SELECT/INSERT: REC HYGIENE INTERVAL]

Next visit: [SELECT/INSERT: NEXT VISIT]
Date Booked: