Nama :

RM
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NO: Tanggal Lahir :
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Jenis Kelamin :
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ANAMNESIS

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Vital Sign:
Tekanan darah:______mmHg Nadi:______x/m R.Rate:______x/m Temp:______OC

Penyakit Jantung :
Diabetes :
Haemophilia :
Hepatitis :
Penyakit Lainnya :
Alergi Obat-obatan :
Alergi Makanan :

Oklusi : Normal Bite/Cross Bite/Step Bite

Torus Palatinus : Tidak ada /Kecil/Sedang/Besar/Multiple
Palatum : Dalam/Sedang/Rendah
Supernumeraty teeth : Tidak Ada/Ada:___________________________________________________________
Diastema : Tidak Ada/Ada:___________________________________________________________
Gigi Anomali : Tidak Ada/Ada:___________________________________________________________
Lain-lain : __________________________________________________________________________
Tanggal Pemeriksaan Keterangan