OFP objective exam template

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posted 2022-01-02, updated 2022-01-02
Dental
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Objective:

Physical Exam/Relevant Findings noted below: 
Neuro Exam (CN 2-12): WNL and alert and oriented x3
Gait: WNL
Extraoral: WNL
Mallampti: [select name="variable_mallampati" value="I|II|III|IV"]
Tonsil: [select name="variable_mallampati" value="0|I|II|III|IV"]
Tongue scalloping: [select name="variable_three levels" value="none|mild|moderate|severe"]
Cheek ridging:  [select name="variable_three levels" value="none|mild|moderate|severe"]
Attrition:  [select name="variable_three levels" value="none|mild|moderate|severe"]

Mandibular ROM(mm): 
Opening path: 
[select name="variable directions2" value="straight|left|right|left and right"];
[select name="deviation/deflection" value="no deviation/deflection|deflection|deviation"]
Comfort jaw opening:  [select name="measurement" value="1|	2|	3|	4|	5|	6|	7|	8|	9|	10|	11|	12|	13|	14|	15|	16|	17|	18|	19|	20|	21|	22|	23|	24|	25|	26|	27|	28|	29|	30|	31|	32|	33|	34|	35|	36|	37|	38|	39|	40|	41|	42|	43|	44|	45|	46|	47|	48|	49|	50|	51|	52|	53|	54|	55|	55+"]
Active jaw opening: [select name="measurement" value="1|	2|	3|	4|	5|	6|	7|	8|	9|	10|	11|	12|	13|	14|	15|	16|	17|	18|	19|	20|	21|	22|	23|	24|	25|	26|	27|	28|	29|	30|	31|	32|	33|	34|	35|	36|	37|	38|	39|	40|	41|	42|	43|	44|	45|	46|	47|	48|	49|	50|	51|	52|	53|	54|	55|	55+"]
Passive jaw opening: [select name="measurement" value="1|	2|	3|	4|	5|	6|	7|	8|	9|	10|	11|	12|	13|	14|	15|	16|	17|	18|	19|	20|	21|	22|	23|	24|	25|	26|	27|	28|	29|	30|	31|	32|	33|	34|	35|	36|	37|	38|	39|	40|	41|	42|	43|	44|	45|	46|	47|	48|	49|	50|	51|	52|	53|	54|	55|	55+"]; [select name="end feel" value="hard|soft"]
Protrusive jaw opening: [select name="measurement" value="1|	2|	3|	4|	5|	6|	7|	8|	9|	10|	11|	12|	13|	14|	15|	16|	17|	18|	19|	20|	21|	22|	23|	24|	25|	26|	27|	28|	29|	30|	31|	32|	33|	34|	35|	36|	37|	38|	39|	40|	41|	42|	43|	44|	45|	46|	47|	48|	49|	50|	51|	52|	53|	54|	55|	55+"]
Right Lateral jaw movement:[select name="measurement" value="1|	2|	3|	4|	5|	6|	7|	8|	9|	10|	11|	12|	13|	14|	15|	16|	17|	18|	19|	20|	21|	22|	23|	24|	25|	26|	27|	28|	29|	30|	31|	32|	33|	34|	35|	36|	37|	38|	39|	40|	41|	42|	43|	44|	45|	46|	47|	48|	49|	50|	51|	52|	53|	54|	55|	55+"]
Left Lateral jaw movement: [select name="measurement" value="1|	2|	3|	4|	5|	6|	7|	8|	9|	10|	11|	12|	13|	14|	15|	16|	17|	18|	19|	20|	21|	22|	23|	24|	25|	26|	27|	28|	29|	30|	31|	32|	33|	34|	35|	36|	37|	38|	39|	40|	41|	42|	43|	44|	45|	46|	47|	48|	49|	50|	51|	52|	53|	54|	55|	55+"]
Mandibular Midline Position: [select name="measurement w/0" value="0|1|	2|	3|	4|	5|	6|	7|	8|	9|	10|	11|	12|	13|	14|	15|	16|	17|	18|	19|	20|	21|	22|	23|	24|	25|	26|	27|	28|	29|	30|	31|	32|	33|	34|	35|	36|	37|	38|	39|	40|	41|	42|	43|	44|	45|	46|	47|	48|	49|	50|	51|	52|	53|	54|	55|	55+"] 
[select name="variable_directions" value="straight|left|right"]
[text name="variable_1" default="sample text"]


TMJ Evaluation: 
Noise: 
[select name="left/right" value="left|right|bilateral"] [checklist name="clicking and crepitus" value="no click|early opening click|mid opening click|late opening click| early closing click| mid closing click| late closing click|no crepitus| mild crepitus| moderate crepitus| severe crepitus| reduced with tongue blades"]



[select name="right/left" value="right|left|bilateral"][checklist name="clicking and crepitus" value="no click|early opening click|mid opening click|late opening click| early closing click| mid closing click| late closing click|no crepitus| mild crepitus| moderate crepitus| severe crepitus| reduced with tongue blades"]
Palpation (pain): 
Orthopedic manipulation (pain): 

General Dental Evaluation
Intraoral: OCS negative. No gross periodontal disease. No gross dental decay. Soft tissues appear grossly wnl. 
Occlusion R - MPCI, ICPM - L: ++++, ++++
Missing dentition: Third molars 

Bite Maneuvers (pain/significant findings noted): 
Intercuspal clench: wnl
Right Separator: wnl
Left separator: wnl
Bilateral separator: wnl

Myofascial Exam(pain/significant findings noted): 
Masseter:
Temporalis:
Trapezius:
SCM:
Occipital Nerves:
Splenius Capitus: 
Other: 

Imaging/Report: none

Other Exam/Dx.Testing:
Objective:

Physical Exam/Relevant Findings noted below:
Neuro Exam (CN 2-12): WNL and alert and oriented x3
Gait: WNL
Extraoral: WNL
Mallampti:
Tonsil:
Tongue scalloping:
Cheek ridging:
Attrition:

Mandibular ROM(mm):
Opening path:
;

Comfort jaw opening:
Active jaw opening:
Passive jaw opening: ;
Protrusive jaw opening:
Right Lateral jaw movement:
Left Lateral jaw movement:
Mandibular Midline Position:




TMJ Evaluation:
Noise:





Palpation (pain):
Orthopedic manipulation (pain):

General Dental Evaluation
Intraoral: OCS negative. No gross periodontal disease. No gross dental decay. Soft tissues appear grossly wnl.
Occlusion R - MPCI, ICPM - L: ++++, ++++
Missing dentition: Third molars

Bite Maneuvers (pain/significant findings noted):
Intercuspal clench: wnl
Right Separator: wnl
Left separator: wnl
Bilateral separator: wnl

Myofascial Exam(pain/significant findings noted):
Masseter:
Temporalis:
Trapezius:
SCM:
Occipital Nerves:
Splenius Capitus:
Other:

Imaging/Report: none

Other Exam/Dx.Testing:

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.95, 21 form elements, 134 boilerplate words, 1 text boxes, 2 check lists, 18 drop downs, 43 total clicks
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