Geriatric Dental Health Evaluation
Patient Information
Name
Age
Gender
Male
Female
Other
Contact Details
Medical History
Relevant Medical Conditions / Medications
Oral Health History
Previous Dental Treatments
Oral Examination
Teeth Status
All Natural
Partial Denture
Complete Denture
Missing Teeth
Implants
Gum Condition
Healthy
Gingivitis
Periodontitis
Receding
Oral Lesions / Ulcers
Signs of Dry Mouth
None
Mild
Moderate
Severe
Functional Assessment
Chewing Ability
Normal
Difficulty
Unable
Speech Difficulties
Oral Hygiene
Brushing
Flossing
Mouthwash
Needs Assistance
Other Observations
Recommendations