chief complaints: mainly write down the location, nature and time of onset (the number of words seems to be less than 27), such as the pain of cold and heat stimulation of the left lower back tooth for 1 days.
current medical history: indicate the differential diagnosis of diseases caused by tooth modification, whether it has been treated, etc.
current medical history: write down whether there is a history of drug allergy, systemic diseases, radiation exposure, etc. For example, patients with tooth extraction can write: denying the history of drug allergy, denying the history of hypertension and heart disease ...
Unless there are special circumstances, the following family history, marriage history and menstrual birth history are generally written without special circumstances.
physical examination: physical examination of the oral cavity, including the whole body, then outside the mouth and finally inside the mouth.
Special examination includes X-ray, CT, etc. If there is one, write it; if there is none, write it.
diagnosis and treatment: write down your diagnosis and treatment of tooth modification.
finally, the doctor's signature.
I won't say much about the patient's name, gender, age, home address, etc. at the front.