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Patient Demographics
Sex:
Age:
The Cause
Cause of Injury:
Other Cause of Injury:
Type of Injury
Avulsion
Intrusive luxation
Extrusive luxation
Lateral luxation
Type of Injury (Other):
Hard Tissue Injury
Teeth Involved: Teeth Map
Click a square on the image to add it to the list
below, or enter the numbers in manually.
For Example: 11,21,22

Crown:
Alveolar/Bone:
Soft Tissue Injury:
Sutures Required:
Treatment Performed
Local Anaesthetic Given:
Repair with GIC:
Repair with GIC & Dycal:
Splinting with GIC:
Other Treatment:
Clinician Type:
Clinician Type (Other):
Dental Kit Evaluation
Was the Book Helpful? (1 Very Helpful ----> 4 Not Helpful)
Were the Kit's Contents Helpful? (1 Very Helpful ----> 4 Not Helpful)
Comments
(Maximum of 50 words)
Upper Tooth: 18 Upper Tooth: 17 Upper Tooth: 16 Upper Tooth: 15 Upper Tooth: 14 Upper Tooth: 13 Upper Tooth: 12 Upper Tooth: 11 Upper Tooth: 21 Upper Tooth: 22 Upper Tooth: 23 Upper Tooth: 24 Upper Tooth: 25 Upper Tooth: 26 Upper Tooth: 27 Upper Tooth: 28 Lower Tooth: 48 Lower Tooth: 47 Lower Tooth: 46 Lower Tooth: 45 Lower Tooth: 44 Lower Tooth: 43 Lower Tooth: 42 Lower Tooth: 41 Lower Tooth: 31 Lower Tooth: 32 Lower Tooth: 33 Lower Tooth: 34 Lower Tooth: 35 Lower Tooth: 36 Lower Tooth: 37 Lower Tooth: 38

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