Dental Hygiene Assessment Sheet
Patient Information
Name
Date of Birth
Date
Gender
Patient ID
Medical History
Medical Conditions
Allergies
Medications
Dental History
Chief Complaint
Previous Dental Treatment
Oral Hygiene Practices
Intraoral Assessment
Teeth Present
Existing Restorations
Prosthetics
Occlusion
Other Observations
Periodontal Assessment
Pocket Depths
Bleeding on Probing
Mobility
Gingival Recession
Oral Hygiene Assessment
Plaque Score
Calculus Deposits
Staining
Oral Mucosa Condition
Risk Factors
Smoking/Tobacco Use
Diabetes
Other Relevant Factors
Assessment Summary
Summary and Recommendations
Assessed By
Signature