Primaria Dental – Patient Clinical Record
🦷 1. Patient Demographic Details
Patient ID
First Name
Last Name
Date of Birth
Age (Auto-calculated)
Gender
Male
Female
Marital Status
Single
Married
Phone Number
Email Address
Address
City / State / ZIP
Emergency Contact Name
Emergency Contact Number
Relationship to Patient
Insurance Provider
Policy Number
🦷 2. Chief Complaint
Description of Complaint
Onset
Duration
Pain Level (1–10)
Aggravating/Relieving Factors
🦷 3. General Medical History
Heart Disease / Heart Attack
High Blood Pressure
Diabetes (Type I or II)
Asthma or Breathing Problems
Allergies (List Below)
Bleeding or Blood Disorders
Hepatitis (A, B, or C)
HIV / AIDS
Kidney Disease
Liver Disease
Seizures / Epilepsy
Thyroid Disorders
Cancer (Type below)
Osteoporosis
Arthritis or Joint Issues
Artificial Joints or Implants
Psychiatric / Mental Health Issues
Other (Specify below)
Allergy Notes / Cancer Type / Other Conditions
🦷 4. Current Medications
Are you taking any medications?
Yes
No
List Medications
🦷 5. Allergies
Do you have any known allergies?
Yes
No
If yes, list them
🦷 6. Past Dental History
Is this your first dental visit?
Yes
No
Past dental experience
Do you use tobacco?
Yes
No
Do you consume alcohol?
Yes
No
🦷 7. Investigations
Radiographs / X-rays Description
If X-ray, specify tooth number
Upload Intraoral Photos
🦷 8. Diagnosis
🦷 9. Treatment Plan
Stepwise Procedures and Notes
✅ 10. Consent & Follow-up
Informed Consent Taken
Yes
No
Next Appointment Date
Patient Signature
Dentist Name
Dentist Signature
Date of Record Entry
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