**Adult Exam**
Nurse: Sarah Jones
c/o: Patient reports sensitivity to cold in upper right molars.
Relevant history: Patient reports the sensitivity started approximately 2 weeks ago. No other symptoms.
Appropriate PPE worn by patient and dentist: Yes, gloves, mask, and eye protection were worn by both.
Patient consents to examination: Yes, patient provided verbal consent.
---
**Medical History**
Updated and reviewed.
Allergies: No known allergies.
Special needs: None.
---
**Social History**
Smoking status: Non-smoker.
Alcohol intake <14 units/week?: Yes.
Dietary information or oral hygiene measures: Patient brushes twice daily and flosses once daily.
---
**Dental History**
Attendance pattern or date of last visit: Last dental visit was 6 months ago for a check-up.
---
**Extra Oral Exam**
Facial asymmetries: None observed.
Neck and lymph nodes: No palpable lymph nodes.
Muscles of mastication: No tenderness to palpation.
Lips: Normal appearance.
TMJ findings: No clicking or popping.
Range of movement/opening: Normal range of motion.
Rotation and translation: Normal.
---
**Intra Oral Exam**
Soft tissues check including:
Tongue: Normal appearance.
Palate: Normal appearance.
Buccal mucosa: Normal appearance.
Lingual mucosa: Normal appearance.
Floor of mouth: Normal appearance.
---
**Occlusion**
ICP stability: Stable.
Posterior support: Adequate.
Protrusive guidance: Canine guidance.
Right excursion: Canine guidance.
Left excursion: Canine guidance.
Interferences: None.
---
**Periodontal Exam**
Oral hygiene: Good.
Gingival biotype: Thick.
Gingival condition: Healthy, no signs of inflammation.
Recession: None.
Mobility: None.
BPE recorded: 0,0,0,0/0,0,0,0
---
**Tooth Surface Loss**
Attrition severity: Mild.
Pathological/physiological: Physiological.
Evidence of parafunction: None.
Erosion severity: None.
BEWE Index: 0.
Abfraction/abrasion severity: None.
Affected surfaces: see iTero scan.
---
**Hard Tissues**
Charting status: Complete.
Caries, defective restorations, cracks, heavily restored teeth: Caries noted on upper right molar.
---
**Aesthetics**
Any concerns reported by the patient: No aesthetic concerns reported.
---
**Radiographs and Special Tests**
Radiographs: Bitewing radiographs taken.
Special tests: Cold sensitivity test positive on upper right molar.
iTero scan status: Completed.
Photos taken: Yes.
---
**Diagnosis/es**
List all diagnoses here: Caries on upper right molar.
Periodontal classification including overview, stage, grade, risk factors: Periodontal health.
---
**Discussions with Patient**
Summary of discussions held about dental health, periodontal condition, tooth wear, diet advice, restorations, or treatment options: Discussed the caries and treatment options, including a filling.
---
**Risk Assessment**
Caries risk: Moderate.
Periodontal risk: Low.
Wear risk: Low.
Oral cancer risk: Low.
---
**Recall Interval**
Recall interval and justification: 6 months, for routine check-up and caries monitoring.
---
**Treatment Plan**
Summarise the overall outcomes and list the agreed actions: Agreed to proceed with a composite filling on the upper right molar.
Written treatment plan provided if mentioned: No.
Patient agreement recorded: Yes.
**Adult Exam**
Nurse: [Name of assisting nurse] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
c/o: [Primary complaints] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Relevant history: [Details of the history of the primary complaints] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Appropriate PPE worn by patient and dentist] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Patient consents to examination] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
---
**Medical History**
Updated and reviewed.
[Allergies] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Special needs] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
---
**Social History**
[Smoking status] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Alcohol intake <14 units/week?] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Dietary information or oral hygiene measures] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
---
**Dental History**
[Attendance pattern or date of last visit] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
---
**Extra Oral Exam**
[Facial asymmetries] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Neck and lymph nodes] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Muscles of mastication] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Lips] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[TMJ findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Range of movement/opening] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Rotation and translation] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
---
**Intra Oral Exam**
Soft tissues check including:
[Tongue] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Palate] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Buccal mucosa] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Lingual mucosa] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Floor of mouth] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
---
**Occlusion**
[ICP stability] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Posterior support] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Protrusive guidance] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Right excursion] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Left excursion] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Interferences] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
---
**Periodontal Exam**
[Oral hygiene] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Gingival biotype] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Gingival condition] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Recession] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Mobility] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[BPE recorded] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
---
**Tooth Surface Loss**
[Attrition severity] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Pathological/physiological] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Evidence of parafunction] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Erosion severity] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[BEWE Index] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Abfraction/abrasion severity] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Affected surfaces: see iTero scan. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
---
**Hard Tissues**
[Charting status] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Caries, defective restorations, cracks, heavily restored teeth] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
---
**Aesthetics**
[Any concerns reported by the patient] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
---
**Radiographs and Special Tests**
[Radiographs] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Special tests] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[iTero scan status] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Photos taken] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
---
**Diagnosis/es**
[List all diagnoses here] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Periodontal classification including overview, stage, grade, risk factors] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
---
**Discussions with Patient**
[Summary of discussions held about dental health, periodontal condition, tooth wear, diet advice, restorations, or treatment options] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
---
**Risk Assessment**
[Caries risk] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Periodontal risk] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Wear risk] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Oral cancer risk] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
---
**Recall Interval**
[Recall interval and justification] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
---
**Treatment Plan**
[Summarise the overall outcomes and list the agreed actions] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Written treatment plan provided if mentioned] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Patient agreement recorded] (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 the transcript or context, else omit section entirely. Never come up with your own patient details, findings, or treatment plans—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 it was not mentioned; 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.)
