Patient Symptom Confirmation Checklist

Patient No: SP-

Please answer each question honestly to help us properly assess your condition and provide the most appropriate recommendation.

1. Are you experiencing pain or sensitivity/discomfort?
Yes
No

2. Do you have swelling or bleeding gums?
Yes
No

3. Do you have difficulty swallowing?
Yes
No

4. Do you have have fever or signs of infection?
Yes
No

5. Have you had recent dental trauma? (Any tooth/teeth, bone and gum injury due to accident, fall, sport or impact)
Yes
No

If you answer “Yes” to any of the above, kindly specify when the symptom occurred or how long it has been present:

Oral Hygiene Instructions

Brush teeth at least twice daily with a soft-bristled brush.

Use fluoridated toothpaste (pea-sized; supervise children).

Replace toothbrush every 3 months or when bristles fray.

Clean between teeth daily:

Floss

Interdental brush

Water flosser

Brush along the gumline and tongue; 2 minutes total.

Optional: Alcohol-free fluoride mouthrinse once daily (do not rinse with water afterward for 30 minutes).

Diet and Habits

Limit sugary/acidic foods and beverages; avoid frequent snacking.

Drink water (2-3L) throughout the day.

Avoid tobacco and limit alcohol.

Post-Treatment Precautions
For dental fillings/inlays/onlays:

Avoid hard, sticky, or chewy foods on the treated side for 24 hours (longer for amalgam: up to 24 hours to fully set).

Report back to Dentist:

Presence of pain or high bite when biting

Restoration with sharp edge and marginal leakage

For crowns/temporary crowns:

Chew on the opposite side; avoid sticky foods; floss by sliding out rather than lifting to avoid dislodging temporary.

For Extraction:

Avoid using straws, spitting or rinsing vigorously and smoking/vaping

Eat soft foods and chew on the opposite side

Rest for 24-48 hrs. No strenuous activity for at least 48 – 72 hours.

Take prescribed medications.

Report back to Dentist:

Bleeding that cannot be controlled by biting on gauze

Severe or worsening pain after 2-3 days

Fever and severe difficulty swallowing or breathing

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