family name								first name								date of birth																													
																																														
	proffession								adress								phone number						employer/school																							
																																														
																																			How to work with form?											
																																														
	stamp of medical department								place of birth																																					
																																			"Fill in fields marked with green color. For suggestion, hover with the cursor over the green field with red corner and help will show up."											
	Date												Signature			Date												Signature																		
																																														
					Periodontologic consultation															tongue description																										
					examination/control																																									
																																														
			DG: 		DIAGNOSIS															Periodontal examination																										
																				"Indexes (PBI, CPITN)"																										
			Med H:																																											
																																														
																																														
																				Gingiva																										
																				color																										
			Fam H:																																											
																				consistency																										
																																														
																				conture																										
																																														
			Farm H:																																											
																				gingival recessions																										
																																														
																																														
																				width of atached gingiva																										
			Allergies:																	phenotype of gingiva																										
																																														
																				Periodontal pockets																										
																																														
																																														
			Smoking																	Furcations																										
																																														
																				Mobility																										
																																														
																				Level of atachement																										
																																														
			SA:																																											
																				Occlusion																										
																																														
																																														
			Clin Ex:																	RTG evaluation																										
																				rtg status (10 images)																										
					extraoral																																									
																																														
																				Other medical examinations																										
																				microbiological evaluation																										
					intraoral																																									
					teeth status																																									
																		Rec:																												
																																														
					oral hygiene level																																									
																																														
																		Th:																												
					state of oral mucous in gingiva region																																									
																																														
																				Oral hygiene instructions																										
																																														
					color																																									
					moisture																																									
																																														
																																														
					examination of oral musous