Dr. M. Narimani
Registered as a General Dentist in Ontario
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Professional Google Forms Template – Dental Hygiene Clinical Notes
Use this document as the blueprint to recreate the form in Google Forms.

1. Sterilization

MM slash DD slash YYYY
MM slash DD slash YYYY
MM slash DD slash YYYY
MM slash DD slash YYYY

2. Medical History

Medical history reviewed
Medications
Allergies
Blood Pressure
Contraindications
Premedication

3. Informed Consent

Discussed the objectives, questions answered, Informed Consent Taken.

4. Chief Complaint

Chief Concern

5. EO/IO Examination

EO/IO Examination

6. Radiographs

Radiographs

7. Periodontal Assessment

Diagnosis
plaque
Recession
Mobility
Furcation

8. Patient Education

Patient Education

9. Treatment

Instrumentation time
Prophy paste
Fluoride
Treatment tolerated very well

10. COE

COE Findings, see the chart

11. Recall

Recall

12. Standard Education Macros

Standard Education Macros

13. Provider

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1. Sterilization
Cassette Load : {Cassette Load::115}
Cassette Date : {Cassette Date::594}
Cavitron Tip Load : {Cavitron Tip Load::291}
Cavitron Date : {Cavitron Date::296}
Handpiece Load : {Handpiece Load::276}
Handpiece Date : {Handpiece Date::298}
X-ray Holder/XCP Kit Load : {X-ray Holder/XCP Kit Load::225}
XCP Date : {XCP Date::299}
2. Medical History
Medical history reviewed : {No changes:302.1} {Changes documented:302.2}
Medications : {No medications:303.1} {No changes:303.2} {Changes documented:303.3}
Medication list : {Medication list:304}
Allergies : {NKDA:305.1} {Allergies documented:305.2}
Allergy details : {Allergy details::306}
Blood Pressure : {Normal:350.1} {Taken:350.2}
Blood Pressure : {Blood pressure::307}
Taken Pulse : {Taken Pulse::308}
Respirations : {Respirations::309}
Contraindications : {None:310.1} {None:310.2
Premedication : {Not required:311.1} {Taken as prescribed:311.2} {Not taken:311.3}
3. Informed Consent
Discussed the objectives, questions answered, Informed Consent Taken. : {EO/IO exam:314.1} {Oral cancer screening:314.2} {Periodontal assessment:314.3} {Periodontal charting:314.4} {Radiographs:314.5} {Debridement:314.6} {Hand scaling:314.7} {Ultrasonic instrumentation:314.8} {Coronal polish:314.9} {Fluoride varnish:314.10} {Local anesthesia:314.11} {Oraqix:314.12} {Other:314.13} {Comments::121}
Periodontal assessment
Comments : {Comments:121}
Chief Concern : {Chief Concern:335}
Chief Concern : {Chief Concern:335}
4. Chief Complaint
Chief Concern : {Routine recare:335.1} {Sensitivity:335.2} {Bleeding gums:335.3} {Broken tooth:335.4} {Stain:335.5} {No concerns:335.6} {Other:335.7} {Comments:336}
5. EO/IO Examination
EO/IO Examination : {WNL:316.1} {Oral cancer screening completed:316.2} {TMJ WNL:316.3} {TMJ clicking:316.4} {Soft tissue findings discussed:316.5} {Xerostomia:316.6} {Referral recommended:316.7} {Comments::289}
6. Radiographs
Radiographs : {Reviewed:319.1} {None indicated:319.2} {2 BW:319.3} {4 BW:319.4} {PA(s):319.5} {FMX:319.6} {PAN reviewed:319.7}
Findings : {Findings::24}
7. Periodontal Assessment
Diagnosis : {Healthy:322.1} {Plaque-induced gingivitis:322.2} {Localized gingivitis:322.3} {Generalized gingivitis:322.4} {Stable periodontitis:322.5} {Periodontitis:322.6} {Periodontal Maintenance:322.7}
plaque : {plaque:323.1} {Supragingival calculus:323.2} {Subgingival calculus:323.3} {Bleeding:323.4} {Stain None:323.5} {Stain Light:323.6} {Stain Moderate:323.7} {Stain Heavy:323.8}
Recession : {None:324.1} {Localized:324.2} {Generalized:324.3}
Mobility : {None:326.1} {Present:326.2}
Furcation : {None:325.1} {Present:325.2} {Comment::34}
8. Patient Education
Patient Education : {Periodontal disease:327.1} {Bone loss:327.2} {Brushing:327.3} {Flossing:327.4} {Interdental aids:327.5} {Water Flosser:327.6} {Fluoride:327.7} {Diet:327.8} {Caries prevention:327.9} {Recession:327.10} {Root caries:327.11} {Sensitivity:327.12} {Smoking/vaping cessation:327.13} {Dry mouth:327.14} {Implant care:327.15} {Orthodontic hygiene:327.16} {Denture care:327.17} {Additional education:333}
9. Treatment
Instrumentation time : {30 min:329.1} {40 min:329.2} {45 min:329.3} {60 min:329.3}
Prophy paste : {None:330.1} {Fine:330.2} {Medium:330.3} {Coarse:330.4}
Fluoride : {5% NaF:331.1} {Clinpro:331.2} {Declined:331.3}
Treatment tolerated very well : {Yes:332.1} {No:332.2}
Complications : {Complications::328}
10. COE
Dentist : {Dentist::338}
COE Findings, see the chart : {No restorative needs:337.1} {Restorative treatment recommended:337.2} {Referral recommended:337.3} {Treatment plan reviewed:337.4} {Comments:339}
11. Recall
Recall : {3-month PM:341.1} {4-month recall:341.2} {6-month recall:341.3} {Other:341.4} {Other recall:342}
12. Standard Education Macros
Standard Education Macros : {Gingival recession discussed:344.1} {Brushing/flossing reviewed:344.2} {Black stain prevention:344.3} {Periodontal maintenance importance:344.4} {Sensitivity management:344.5}
Provider
Provider : {Provider::169}
Signature : {Signature::346}

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