Q1.Assessment of fit
Q2.Occlusion of working cast
Q3.Proximal contacts
Q4.Material used
Q5.Crown acceptable
Q6.Did PT return adj temp crown
Q7.Was temp in place entire time
Q8.Crown clinically acceptable
Q9.Crown fit
Q10.Marginal fit of crown
Q11.Proximal fit of crown
Q12.Occlusal assessment
Q13.Esthetics of crown
Q14.Rate level Pt expect esthetics
Q15.Cement materials
Q16.Primary reason crown rejected
Q17.Main reason crown did not fit
Year & Month of Visit