Comprehensive periodontal evaluation

[patient's age] [patient's sex] presented for evaluation of [reason for today's appointment] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely). The patient was referred by [source of the referral and reason for the referral] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely). [Auxiliary personnel involved in today's appointment] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely). Chief Complaint: - [insert chief complaint along with duration] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely) History of Presenting Complaints: - [detailed description of all complaints including onset, progression, aggravating or alleviating factors, associated symptoms, duration, intensity, nature, frequency of symptoms, etc.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely) - [description of any cosmetic concerns] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely) Past Dental History: - [previous dental treatments, surgeries, significant dental diseases or injuries, etc. Include dates and outcomes of treatments] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely) Past Medical History: - [Medical history] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely) - [Medications, including current prescribed medications, over-the-counter drugs, and supplements; grouped per medical condition] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely) - [Surgical history] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely) - [Family history relevant to the reasons for visit or medical conditions] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely) - [Social history: relevant social factors, including smoking, alcohol, drug use, or occupational exposures] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely) - [Allergies, including details on reactions] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely) - [Immunization history & status] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely) - [Other relevant history or contributing factors] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely) Personal History: - [patient's past oral hygiene practices] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely) - [habits such as clenching, grinding, biting, tobacco chewing, smoking, alcohol intake, etc.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely) Extra Oral Physical Examination: - [vital signs recorded during the appointment] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely) - [Physical or mental state examination findings, including system specific examination(s)] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely) - [extra-oral examination findings such as lymph node examination, facial symmetry, lip] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely; if extra oral examination is performed but results are not explicitly described, write "No facial asymmetries. Inferior border of mandible palpable. No pain on palpation. No CLAD.") - [results of TMJ examination such as range of motion, 3-finger mouth opening test, deviation upon opening, pain upon opening or palpation, soreness of muscles of mastication] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely) - [other extra oral examination findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely) Intra Oral Examination: - [soft tissue examination findings including findings on buccal mucosa, tongue, palate, floor of the mouth, vestibule, etc.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely; if no information is provided then use "No sores or lesions noted on gingiva, buccal mucosa, FOM, hard/soft palate, lateral borders of tongue. Floor of mouth soft, uvula midline. No swellings, no purulence, moist mucous membranes. Copious saliva.") - [other intra oral examination findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely) Periodontal and Peri-implant Findings: - [findings on oral hygiene status, e.g., good/fair/poor based on OHI index, etc.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely) - [gingival examination findings including color, contour, size, consistency, surface texture, position, periodontal and peri-implant phenotype, plaque index, locations of calculus, bleeding along with bleeding position, exudation, amount of keratinized gingiva, probing depths with probing position, gingival recession with recession position, positions and grade of dental mobility, positions and grade of furcation involvement, etc.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely) Dental Findings: - [hard tissue examination findings like number of teeth present, missing teeth, dental caries, restored teeth, periapical problems, pathologic migration, overhanging restorations, impacted teeth, supernumerary teeth, wasting disease such as attrition/abrasion/erosion/abfraction, mobility grading, shade analysis, stains / deposits, etc.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely) Occlusal findings: - [occlusion analysis findings such as type of occlusion (Angles classification, etc), overbite, overjet, crossbite, open contacts, crowding, facets, supra contacts, trauma from occlusion, Fremitus test, etc.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely) Radiographic Findings: - [findings from dental radiographs, noting any pathologies like caries/cysts/tumours, tooth positions, bone levels, etc. and comparisons with previous radiographs] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely) Laboratory Investigations: - [investigations, along with results, such as blood counts, hemoglobin, platelet count, bleeding time, clotting time, ESR, blood sugar, etc.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely) - [biopsy findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely) Diagnoses: - [diagnoses] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely) Prognosis: - [overall prognosis] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely) - [individual prognosis for teeth or implants at risk] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely) Treatment: - [treatment plans/recommendations] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely) - [preventative plans such as oral hygiene recommendations] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely) - [review date or follow-up plans] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely) Next visit: [date and purpose of the next visit] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely) (For each section, only include if explicitly mentioned in transcript or context, else omit section entirely. Never come up with your own patient details, assessment, plan, interventions, evaluation, or next steps—use only the transcript, contextual notes, or clinical note as reference for all information. If any information related to a placeholder has not been explicitly mentioned, do not state that in the output; simply leave the relevant placeholder or section out entirely. Use as many lines, paragraphs, or bullet points as needed to capture all relevant information from the transcript.)