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    Form. Odontogram

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    enik
    This document contains a dental odontogram form used at RUMAH SAKIT UTAMA HUSADA hospital. The form collects patient information such as name, gender, medical record number, and date of birth/age. It also contains a chart to document the condition of each tooth as well as areas to note the occulsion, presence of torus palatinus/mandibularis, palate shape, diastema, anomalous teeth, and other notes. There are also sections to record the number of photos taken and x-rays. The form is to be filled out and signed by the examining dentist.

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    © All Rights Reserved
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    Form. Odontogram

    Uploaded by

    enik
    191 views1 page
    This document contains a dental odontogram form used at RUMAH SAKIT UTAMA HUSADA hospital. The form collects patient information such as name, gender, medical record number, and date of birth/age. It also contains a chart to document the condition of each tooth as well as areas to note the occulsion, presence of torus palatinus/mandibularis, palate shape, diastema, anomalous teeth, and other notes. There are also sections to record the number of photos taken and x-rays. The form is to be filled out and signed by the examining dentist.

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    odonto

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    This document contains a dental odontogram form used at RUMAH SAKIT UTAMA HUSADA hospital. The form collects patient information such as name, gender, medical record number, and date of birth/age. It also contains a chart to document the condition of each tooth as well as areas to note the occulsion, presence of torus palatinus/mandibularis, palate shape, diastema, anomalous teeth, and other notes. There are also sections to record the number of photos taken and x-rays. The form is to be filled out and signed by the examining dentist.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    191 views1 page

    Form. Odontogram

    Uploaded by

    enik
    This document contains a dental odontogram form used at RUMAH SAKIT UTAMA HUSADA hospital. The form collects patient information such as name, gender, medical record number, and date of birth/age. It also contains a chart to document the condition of each tooth as well as areas to note the occulsion, presence of torus palatinus/mandibularis, palate shape, diastema, anomalous teeth, and other notes. There are also sections to record the number of photos taken and x-rays. The form is to be filled out and signed by the examining dentist.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 1

    RUMAH SAKIT UTAMA HUSADA

    Jalan Manggar 134 Tegalsari – Ambulu


    Telp. (0336) – 881186, 881187

    FORMULIR PEMERIKSAAN ODONTOGRAM


    NAMA LENGKAP : ........................................................ JENIS KELAMIN :L/P
    No. RM : ........................................................ Tgl Lahir/Umur : ……………..

    11 [51] [61] 21
    12 [52] [62] 22
    13 [53] [63] 23
    14 [54] [64] 24
    15 [55] [65] 25
    16 26
    17 27
    18 28
    18 171615 14 13 12 11 21 22 23 24 25 26 27 28

    55 54 53 52 51 61 62 63 64 65

    85 84 83 82 81 71 72 73 74 75

    48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38

    48 38
    47 37
    46 36
    45 [54] [75] 35
    44 [51] [74] 34
    43 [52] [73] 33
    42 [53] [72] 32
    41 [54] [71] 31

    Occlusi : Normal Bite / Cross Bite / Steep Bite


    Torus Palatinus : Tidak Ada / Kecil / Sedang / Besar / Multiple
    Torus Mandibularis : Tidak ada / sisi kiri / sisi kanan / kedua sisi
    Palatum : Dalam / Sedang / Rendah
    Diastema : Tidak Ada/ Ada: (dijelaskan dimana dan berapa lebarnya) ........................
    Gigi Anomali : Tidak Ada / Ada: (dijelaskan gigi yang mana, dan bentuknya) ..................
    Lain-lain : (hal-hal yang tidak tercakup diatas) ...............................................................
    D : ...... M : ....... F : ......

    Jumlah photo yang diambil…………………. (digital/intraoral)*


    Jumlah rontgen photo yang diambil ………..(Dental/PA/OPG/Ceph)*
    DIPERIKSA OLEH : TANGGAL PEMERIKSAAN TANDA TANGAN PEMERIKSA

    drg................................. ..... /...../....................... ......................................................

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