Confidential Prosthodontic Evaluation
A. PATIENT: ______________________________________ DATE: ____________________
B. REPORTED CHIEF COMPLAINT: ___________________________________________
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C. REPORTED MEDICAL HISTORY: ___________________________________________
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D. REPORTED PROSTHODONTIC HISTORY: ___________________________________
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E. SIGNIFICANT INITIAL EXAMINATION FINDINGS AS APPLICABLE:
1. Mandible: _____ Complete edentulism _____ Partial edentulism
2. Maxilla: _____ Complete edentulism _____ Partial edentulism
3. Missing teeth #s: _____________________________________________
4. Periodontal: ____ Generalized _____ Local _____ Chronic _____ Acute____ Negative
5. Oral Hygiene: _____ Good _____ Fair _____ Poor: _______________
6. ____Prosthesis and/or: ___ Dentition Condition: ___ Acceptable ___ Non-acceptable
7. Salivary Consistency: _____ Mucoid _____ Serous ______ Mixed ______ Xerostomia
8. Pathology: _____________________________________________________________
9. Muscle Tone: _______ Normal _______ Flaccid ________ Hypertonic: ___________
10. Tongue Position: _____ Normal _____ Retracted _____ Hyperactive: ____________
11. TMJ: _____ Asymptomatic _____ Symptomatic
_____ Right ____ Left
_____ Crepitus _____ Luxation
12. Occlusion: ____ Acceptable _____ Non-acceptable: ______________
13. Facial Symmetry: _____ Normal _____ Asymmetrical _____ Right _____ Left
14. Jaw Relationship: _____ I _____ II _____ III _____ Pseudo: _______________
15. Vertical Dimension: ____ Normal ____ Open _____ Closed: ________________
16. Intra-Occlusal Relation: _____ Acceptable _____ Excessive ______ Insufficient
17. Topography: ____ Acceptable ____ Irregular _____ Maxilla _____ Mandible
18. Arch Form: ____ Square ____ Taper ____ Ovoid:
19. Muscle Attachments: ____ Normal ____ Impinging ____ Maxilla ____ Mandibular
20. Tuberosities: ______ Acceptable ______ Impinging _____ Right _____ Left
21. Mylohyoid Ridges: _______ Acceptable ______ Impinging _____ Right _____ Left
22. Throat-Pharyngeal ______ Normal ______ Abnormal _____ Gag Reflex ______
F. PSYCHOLOGICAL STATUS: _____ Philosophical
_____ Indifferent
_____ Exacting
_____ Hysterical
_____ Apprehensive
_____ Unrealistic
Patient Management Problem: ___________________
G. PRELIMINARY PROGNOSIS: _____ Excellent _____Fair _____ Poor _____ Guarded
H. COMMENTS AND TREATMENT RECOMMENDATIONS: ______________________
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Michael L. Linebaugh, DDS MS ŠUniversity of Detroit Mercy 2004
