Q1. TOOTH Number
Q2. Deepest margin of preparation
Q3. Primary reason for crowning
Q4. Finish line
Q5. Tooth mobility
Q6. Treated endo
Q7. Foundation for build-up
Q8_1. Mesial contact
Q8_2. Distal contact
Q8_3. No proximal contact
Q9_1. Opp tooth:Natural
Q9_2. Opp tooth:Fixed crown/bridge
Q9_3. Opp tooth:RPD
Q9_4. Opp tooth:Full denture
Q9_5. Opp tooth:Nothing
Q10. Crown has contact w/RPD
Q11. PT Esthetic expectation
Q12. Impression technique
Q13_1. Retract tech:None
Q13_2. Retract tech:Single cord
Q13_3. Retract tech:Dual cord
Q13_4. Retract tech:Injectable retract material
Q13_5. Retract tech:Dual impression
Q13_6. Retract tech:Gingival troughing
Q13_7. Retract tech:Cotton cap
Q13_99. Retract tech:Other
Q14. Impression mat/tech used
Q15. Who made final impression
Q16. Rate hemostasis dur impression
Q17. Who made temp for crown
Q18. What used record inter-aech occlusion
Q19. Overall difficulty of making impressiom
Q20. How many impresions made today
Q21_1. Factors re impression: Bleeding
Q21_2. Factors re impression: Deep margins
Q21_3. Factors re impression: PT gagging
Q21_4. Factors re impression: Excessive salivation
Q21_5. Factors re impression: Limited opening
Q21_6. Factors re impression: PT anxiety
Q21_7. Factors re impression: PT muscle control/coop
Q21_98. Factors re impression: Other
Q22_1. Who selected crown shade: Dentist
Q22_2. Who selected crown shade: An asssistant
Q22_3. Who selected crown shade: Lab tech
Q22_4. Who selected crown shade: Patient
Q22_98. Who selected crown shade: Other
Year Month of Visit