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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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