Dental Implant Surgery Follow-Up Evaluation Form
Patient Name
Date of Evaluation
Date of Birth
Implant Location
1. General Assessment
Healing Progress
Uneventful
Mild Issues
Delayed
Complicated
Pain Level
None
Mild
Moderate
Severe
Swelling
None
Mild
Moderate
Severe
Signs of Infection
No
Yes
2. Implant Site Evaluation
Implant Mobility
None
Slight
Pronounced
Peri-implant Tissue Condition
Healthy
Inflamed
Recession
Suppuration
No
Yes
3. Additional Notes & Recommendations
Notes