Orthodontic Associates, Ltd.| Orthodontist Flossmoor New ...
Date:
MEDICAL SUMMARY REPORT FORM
IDENTIFICATION:
Patient’s Name:
S.S.N./S.I.N.: Date of Birth: Sex: Male Female
Address:
City: State/Province Zip/Postal Code: Phone: ( ) -
SIGNIFICANT HISTORY: (Nature of Traumatic Injury or Pertinent Past Medical History)
Traumatic injury as a result of: DESCRIPTION OF ACCIDENT/INJURY:
| Motor Vehicle Accident |Date: | |
|Occupational Injury | | |
|Accidental Injury | | |
| | | |
| | | |
| | | |
|Pertinent Past Medical History: | | |
SUBJECTIVE SYMPTOMS: Check the complaints the patient reported at the time of initial examination.
Frequent Headaches
Dizziness/Vertigo
Lightheadedness
Tinnitus or Ringing in Ears
Ear/Sinus Congestion
Paresthesia in Fingertips
Backaches (upper/lower)
Neckaches or stiffness
Difficulty opening/closing mouth
Inability to fully open the mouth
Jaw Clicking
Jaw/Joint Pain
Facial Pain or Muscle Fatigue
Referred Odontalgia (tooth pain)
Sore Throat or Gagging Sensation
Chronic Fatigue
Eye Pain or Visual Disturbances
Frequent Stress
OBJECTIVE CLINICAL FINDINGS: Clinical examination of this patient revealed the following:
JOINT PALPATION: Right Left
Pain on palpation of TM joint extraorally
Pain on palpation of TM joint intrameatilly
Pain on opening/closing
Crepitation on opening/closing
Click on opening/closing/reciprocal
MANDIBULAR FUNCTION: Right Left
Midline Deviation of mm. to the
Mandibular Deviation on opening/closing
Hypermobility
Subluxation on opening/closing
Limited opening
Range of Motion: Opening mm.
Left Lateral mm. Right Lateral mm.
MUSCLE TESTING: Right Left
Pain on Masticatory Function
Pain on palpation of Masseter
Pain on palpation of Temporalis
Pain on palpation of External Pterygoid
Pain on palpation of Internal Pterygoid
Pain on palpation of Sternocleidomastoids
Pain on palpation of Trapezius
Pain on palpation of Posterior Cervicals
OTHER FINDINGS:
RADIOGRAPHIC FINDINGS: Type of Radiographs Obtained: Number of Views:
X-rays Revealed: Right Left
Normal View
Anterior Displacement
Posterior Displacement
Superior Displacement
Inferior Displacement
X-rays Revealed: Right Left
Loss of Motion
Ankylosis
Subluxation
Dislocation
Osteoarthritic Changes
Morphologic Changes:
DIAGNOSIS:
PROGNOSIS:
Signature: __________________________________________________________________________ Date: ________________________
(Orthodontist)
Phone number: ( ) -
Address:
City: State/Province Zip/Postal Code:
SUMMARY ATTACHMENT FOR MEDICAL CLAIM FORM:
© American Association of Orthodontists 1999
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