Subject ID
Treatment Round
Q1. Tooth 2 circled sensitive in upper arch
Q1. Tooth 3 circled sensitive in upper arch
Q1. Tooth 4 circled sensitive in upper arch
Q1. Tooth 5 circled sensitive in upper arch
Q1. Tooth 6 circled sensitive in upper arch
Q1. Tooth 7 circled sensitive in upper arch
Q1. Tooth 8 circled sensitive in upper arch
Q1. Tooth 9 circled sensitive in upper arch
Q1. Tooth 10 circled sensitive in upper arch
Q1. Tooth 11 circled sensitive in upper arch
Q1. Tooth 12 circled sensitive in upper arch
Q1. Tooth 13 circled sensitive in upper arch
Q1. Tooth 14 circled sensitive in upper arch
Q1. Tooth 15 circled sensitive in upper arch
Q1. Tooth 2 buccal/facial restoration marked
Q1. Tooth 2 mesial restoration marked
Q1. Tooth 2 distal restoration marked
Q1. Tooth 2 occlusal restoration marked
Q1. Tooth 2 lingual restoration marked
Q1. Tooth 3 buccal/facial restoration marked
Q1. Tooth 3 mesial restoration marked
Q1. Tooth 3 distal restoration marked
Q1. Tooth 3 occlusal restoration marked
Q1. Tooth 3 lingual restoration marked
Q1. Tooth 4 buccal/facial restoration marked
Q1. Tooth 4 mesial restoration marked
Q1. Tooth 4 distal restoration marked
Q1. Tooth 4 occlusal restoration marked
Q1. Tooth 4 lingual restoration marked
Q1. Tooth 5 buccal/facial restoration marked
Q1. Tooth 5 mesial restoration marked
Q1. Tooth 5 distal restoration marked
Q1. Tooth 5 occlusal restoration marked
Q1. Tooth 5 lingual restoration marked
Q1. Tooth 6 buccal/facial restoration marked
Q1. Tooth 6 mesial restoration marked
Q1. Tooth 6 distal restoration marked
Q1. Tooth 6 occlusal restoration marked
Q1. Tooth 6 lingual restoration marked
Q1. Tooth 7 buccal/facial restoration marked
Q1. Tooth 7 mesial restoration marked
Q1. Tooth 7 distal restoration marked
Q1. Tooth 7 occlusal restoration marked
Q1. Tooth 7 lingual restoration marked
Q1. Tooth 8 buccal/facial restoration marked
Q1. Tooth 8 mesial restoration marked
Q1. Tooth 8 distal restoration marked
Q1. Tooth 8 occlusal restoration marked
Q1. Tooth 8 lingual restoration marked
Q1. Tooth 9 buccal/facial restoration marked
Q1. Tooth 9 distal restoration marked
Q1. Tooth 9 mesial restoration marked
Q1. Tooth 9 occlusal restoration marked
Q1. Tooth 9 lingual restoration marked
Q1. Tooth 10 buccal/facial restoration marked
Q1. Tooth 10 distal restoration marked
Q1. Tooth 10 mesial restoration marked
Q1. Tooth 10 occlusal restoration marked
Q1. Tooth 10 lingual restoration marked
Q1. Tooth 11 buccal/facial restoration marked
Q1. Tooth 11 distal restoration marked
Q1. Tooth 11 mesial restoration marked
Q1. Tooth 11 occlusal restoration marked
Q1. Tooth 11 lingual restoration marked
Q1. Tooth 12 buccal/facial restoration marked
Q1. Tooth 12 distal restoration marked
Q1. Tooth 12 mesial restoration marked
Q1. Tooth 12 occlusal restoration marked
Q1. Tooth 12 lingual restoration marked
Q1. Tooth 13 buccal/facial restoration marked
Q1. Tooth 13 distal restoration marked
Q1. Tooth 13 mesial restoration marked
Q1. Tooth 13 occlusal restoration marked
Q1. Tooth 13 lingual restoration marked
Q1. Tooth 14 buccal/facial restoration marked
Q1. Tooth 14 distal restoration marked
Q1. Tooth 14 mesial restoration marked
Q1. Tooth 14 occlusal restoration marked
Q1. Tooth 14 lingual restoration marked
Q1. Tooth 15 buccal/facial restoration marked
Q1. Tooth 15 distal restoration marked
Q1. Tooth 15 mesial restoration marked
Q1. Tooth 15 occlusal restoration marked
Q1. Tooth 15 lingual restoration marked
Q2. Tooth 2 Visible Dentin
Q2. Tooth 2 Gingival Recession
Q2. Tooth 2 No Restoration
Q2. Tooth 2 Amalgam
Q2. Tooth 2 Resin
Q2. Tooth 2 PFM Restoration
Q2. Tooth 2 All Porcelain
Q2. Tooth 2 Cast Metal
Q2. Tooth 2 Other Restoration
Q2. Tooth 3 Visible Dentin
Q2. Tooth 3 Gingival Recession
Q2. Tooth 3 No Restoration
Q2. Tooth 3 Amalgam
Q2. Tooth 3 Resin
Q2. Tooth 3 PFM Restoration
Q2. Tooth 3 All Porcelain
Q2. Tooth 3 Cast Metal
Q2. Tooth 3 Other Restoration
Q2. Tooth 4 Visible Dentin
Q2. Tooth 4 Gingival Recession
Q2. Tooth 4 No Restoration
Q2. Tooth 4 Amalgam
Q2. Tooth 4 Resin
Q2. Tooth 4 PFM Restoration
Q2. Tooth 4 All Porcelain
Q2. Tooth 4 Other Restoration
Q2. Tooth 5 Visible Dentin
Q2. Tooth 5 Gingival Recession
Q2. Tooth 5 No Restoration
Q2. Tooth 5 Amalgam
Q2. Tooth 5 Resin
Q2. Tooth 5 PFM Restoration
Q2. Tooth 5 All Porcelain
Q2. Tooth 5 Cast Metal
Q2. Tooth 5 Other Restoration
Q2. Tooth 6 Visible Dentin
Q2. Tooth 6 Gingival Recession
Q2. Tooth 6 No Restoration
Q2. Tooth 6 Resin
Q2. Tooth 6 PFM Restoration
Q2. Tooth 6 All Porcelain
Q2. Tooth 7 Visible Dentin
Q2. Tooth 7 Gingival Recession
Q2. Tooth 7 No Restoration
Q2. Tooth 7 Resin
Q2. Tooth 7 Cast Metal
Q2. Tooth 7 Other Restoration
Q2. Tooth 8 Visible Dentin
Q2. Tooth 8 Gingival Recession
Q2. Tooth 8 No Restoration
Q2. Tooth 8 Resin
Q2. Tooth 8 All Porcelain
Q2. Tooth 8 Other Restoration
Q2. Tooth 9 Visible Dentin
Q2. Tooth 9 Gingival Recession
Q2. Tooth 9 No Restoration
Q2. Tooth 9 Resin
Q2. Tooth 9 All Porcelain
Q2. Tooth 9 Other Restoration
Q2. Tooth 10 Visible Dentin
Q2. Tooth 10 Gingival Recession
Q2. Tooth 10 No Restoration
Q2. Tooth 10 Amalgam
Q2. Tooth 10 Resin
Q2. Tooth 11 Visible Dentin
Q2. Tooth 11 Gingival Recession
Q2. Tooth 11 No Restoration
Q2. Tooth 11 Amalgam
Q2. Tooth 11 Resin
Q2. Tooth 11 All Porcelain
Q2. Tooth 11 Cast Metal
Q2. Tooth 11 Other Restoration
Q2. Tooth 12 Visible Dentin
Q2. Tooth 12 Gingival Recession
Q2. Tooth 12 No Restoration
Q2. Tooth 12 Amalgam
Q2. Tooth 12 Resin
Q2. Tooth 12 PFM Restoration
Q2. Tooth 13 Visible Dentin
Q2. Tooth 13 Gingival Recession
Q2. Tooth 13 No Restoration
Q2. Tooth 13 Amalgam
Q2. Tooth 13 Resin
Q2. Tooth 13 PFM Restoration
Q2. Tooth 13 All Porcelain
Q2. Tooth 14 Visible Dentin
Q2. Tooth 14 Gingival Recession
Q2. Tooth 14 No Restoration
Q2. Tooth 14 Amalgam
Q2. Tooth 14 Resin
Q2. Tooth 14 PFM Restoration
Q2. Tooth 14 All Porcelain
Q2. Tooth 14 Cast Metal
Q2. Tooth 14 Other Restoration
Q2. Tooth 15 Visible Dentin
Q2. Tooth 15 Gingival Recession
Q2. Tooth 15 No Restoration
Q2. Tooth 15 Amalgam
Q2. Tooth 15 Resin
Q2. Tooth 15 PFM Restoration
Q2. Tooth 15 All Porcelain
Q2. Tooth 15 Other Restoration
Q3. Tooth 31 circled sensitive in lower arch
Q3. Tooth 30 circled sensitive in lower arch
Q3. Tooth 29 circled sensitive in lower arch
Q3. Tooth 28 circled sensitive in lower arch
Q3. Tooth 27 circled sensitive in lower arch
Q3. Tooth 26 circled sensitive in lower arch
Q3. Tooth 25 circled sensitive in lower arch
Q3. Tooth 24 circled sensitive in lower arch
Q3. Tooth 23 circled sensitive in lower arch
Q3. Tooth 22 circled sensitive in lower arch
Q3. Tooth 21 circled sensitive in lower arch
Q3. Tooth 20 circled sensitive in lower arch
Q3. Tooth 19 circled sensitive in lower arch
Q3. Tooth 18 circled sensitive in lower arch
Q3. Tooth 31 buccal/facial restoration marked
Q3. Tooth 31 mesial restoration marked
Q3. Tooth 31 distal restoration marked
Q3. Tooth 31 occlusal restoration marked
Q3. Tooth 31 lingual restoration marked
Q3. Tooth 30 buccal/facial restoration marked
Q3. Tooth 30 mesial restoration marked
Q3. Tooth 30 distal restoration marked
Q3. Tooth 30 occlusal restoration marked
Q3. Tooth 30 lingual restoration marked
Q3. Tooth 29 buccal/facial restoration marked
Q3. Tooth 29 mesial restoration marked
Q3. Tooth 29 distal restoration marked
Q3. Tooth 29 occlusal restoration marked
Q3. Tooth 29 lingual restoration marked
Q3. Tooth 28 buccal/facial restoration marked
Q3. Tooth 28 mesial restoration marked
Q3. Tooth 28 distal restoration marked
Q3. Tooth 28 occlusal restoration marked
Q3. Tooth 28 lingual restoration marked
Q3. Tooth 27 buccal/facial restoration marked
Q3. Tooth 27 distal restoration marked
Q3. Tooth 27 lingual restoration marked
Q3. Tooth 26 buccal/facial restoration marked
Q3. Tooth 26 distal restoration marked
Q3. Tooth 26 lingual restoration marked
Q3. Tooth 25 buccal/facial restoration marked
Q3. Tooth 25 mesial restoration marked
Q3. Tooth 25 distal restoration marked
Q3. Tooth 25 occlusal restoration marked
Q3. Tooth 25 lingual restoration marked
Q3. Tooth 24 buccal/facial restoration marked
Q3. Tooth 24 mesial restoration marked
Q3. Tooth 24 occlusal restoration marked
Q3. Tooth 24 lingual restoration marked
Q3. Tooth 23 buccal/facial restoration marked
Q3. Tooth 23 distal restoration marked
Q3. Tooth 23 mesial restoration marked
Q3. Tooth 23 lingual restoration marked
Q3. Tooth 22 buccal/facial restoration marked
Q3. Tooth 22 distal restoration marked
Q3. Tooth 22 occlusal restoration marked
Q3. Tooth 22 lingual restoration marked
Q3. Tooth 21 buccal/facial restoration marked
Q3. Tooth 21 distal restoration marked
Q3. Tooth 21 mesial restoration marked
Q3. Tooth 21 occlusal restoration marked
Q3. Tooth 21 lingual restoration marked
Q3. Tooth 20 buccal/facial restoration marked
Q3. Tooth 20 distal restoration marked
Q3. Tooth 20 mesial restoration marked
Q3. Tooth 20 occlusal restoration marked
Q3. Tooth 20 lingual restoration marked
Q3. Tooth 18 buccal/facial restoration marked
Q3. Tooth 18 distal restoration marked
Q3. Tooth 18 mesial restoration marked
Q3. Tooth 18 occlusal restoration marked
Q3. Tooth 18 lingual restoration marked
Q4. Tooth 31 Visible Dentin
Q4. Tooth 31 Gingival Recession
Q4. Tooth 31 No Restoration
Q4. Tooth 31 Amalgam
Q4. Tooth 31 Resin
Q4. Tooth 31 PFM Restoration
Q4. Tooth 31 All Porcelain
Q4. Tooth 31 Cast Metal
Q4. Tooth 30 Visible Dentin
Q4. Tooth 30 Gingival Recession
Q4. Tooth 30 No Restoration
Q4. Tooth 30 Amalgam
Q4. Tooth 30 Resin
Q4. Tooth 30 PFM Restoration
Q4. Tooth 30 All Porcelain
Q4. Tooth 30 Cast Metal
Q4. Tooth 29 Visible Dentin
Q4. Tooth 29 Gingival Recession
Q4. Tooth 29 No Restoration
Q4. Tooth 29 Amalgam
Q4. Tooth 29 Resin
Q4. Tooth 29 PFM Restoration
Q4. Tooth 29 All Porcelain
Q4. Tooth 29 Other Restoration
Q4. Tooth 28 Visible Dentin
Q4. Tooth 28 Gingival Recession
Q4. Tooth 28 No Restoration
Q4. Tooth 28 Amalgam
Q4. Tooth 28 Resin
Q4. Tooth 27 Visible Dentin
Q4. Tooth 27 Gingival Recession
Q4. Tooth 27 No Restoration
Q4. Tooth 27 Resin
Q4. Tooth 27 Cast Metal
Q4. Tooth 26 Visible Dentin
Q4. Tooth 26 Gingival Recession
Q4. Tooth 26 No Restoration
Q4. Tooth 26 Resin
Q4. Tooth 26 All Porcelain
Q4. Tooth 26 Cast Metal
Q4. Tooth 25 Visible Dentin
Q4. Tooth 25 Gingival Recession
Q4. Tooth 25 No Restoration
Q4. Tooth 25 Resin
Q4. Tooth 25 All Porcelain
Q4. Tooth 25 Cast Metal
Q4. Tooth 24 Visible Dentin
Q4. Tooth 24 Gingival Recession
Q4. Tooth 24 No Restoration
Q4. Tooth 24 Resin
Q4. Tooth 24 All Porcelain
Q4. Tooth 24 Cast Metal
Q4. Tooth 23 Visible Dentin
Q4. Tooth 23 Gingival Recession
Q4. Tooth 23 No Restoration
Q4. Tooth 23 Resin
Q4. Tooth 23 Cast Metal
Q4. Tooth 22 Visible Dentin
Q4. Tooth 22 Gingival Recession
Q4. Tooth 22 No Restoration
Q4. Tooth 22 Resin
Q4. Tooth 22 Cast Metal
Q4. Tooth 22 Other Restoration
Q4. Tooth 21 Visible Dentin
Q4. Tooth 21 Gingival Recession
Q4. Tooth 21 No Restoration
Q4. Tooth 21 Amalgam
Q4. Tooth 21 Resin
Q4. Tooth 21 PFM Restoration
Q4. Tooth 21 Cast Metal
Q4. Tooth 20 Visible Dentin
Q4. Tooth 20 Gingival Recession
Q4. Tooth 20 No Restoration
Q4. Tooth 20 Amalgam
Q4. Tooth 20 Resin
Q4. Tooth 20 PFM Restoration
Q4. Tooth 19 Visible Dentin
Q4. Tooth 19 Gingival Recession
Q4. Tooth 19 No Restoration
Q4. Tooth 19 Amalgam
Q4. Tooth 19 Resin
Q4. Tooth 19 PFM Restoration
Q4. Tooth 19 All Porcelain
Q4. Tooth 19 Cast Metal
Q4. Tooth 19 Other Restoration
Q4. Tooth 18 Visible Dentin
Q4. Tooth 18 Gingival Recession
Q4. Tooth 18 No Restoration
Q4. Tooth 18 Amalgam
Q4. Tooth 18 Resin
Q4. Tooth 18 PFM Restoration
Q4. Tooth 18 All Porcelain
Q4. Tooth 18 Cast Metal
Q4. Tooth 18 Other Restoration
Q5 Base. Number of natural teeth present (3rd molars excluded)
Q6 Base. Number of natural posterior teeth present
Q7 Base/Q5 Sympt. PT expense for prevent/problem focused exam
Q8 Base/Q6 Sympt. Fluoride Recommended
Q8 Base/Q6 Sympt. Fluoride Duration
Q8 Base/Q6 Sympt. Fluoride Frequency
Q8 Base/Q6 Sympt. Fluoride Gel Recommended
Q8 Base/Q6 Sympt. Fluoride Gel Duration
Q8 Base/Q6 Sympt. Fluoride Gel Frequency
Q8 Base/Q6 Sympt. Fluoride Varnish Recommended
Q8 Base/Q6 Sympt. Fluoride Varnish Duration
Q8 Base/Q6 Sympt. Fluoride Varnish Frequency
Q8 Base/Q6 Sympt. Fluoride Paste Recommended
Q8 Base/Q6 Sympt. Fluoride Paste Duration
Q8 Base/Q6 Sympt. Fluoride Paste Frequency
Q8 Base/Q6 Sympt. Fluoride Rinse Recommended
Q8 Base/Q6 Sympt. Fluoride Rinse Duration
Q8 Base/Q6 Sympt. Fluoride Rinse Frequency
Q8 Base/Q6 Sympt. Desensitizing OTC KNO3 toothpastes Rec
Q8 Base/Q6 Sympt. Desensitizing OTC KNO3 toothpastes Duration
Q8 Base/Q6 Sympt. Desensitizing OTC KNO3 toothpastes Frequency
Q8 Base/Q6 Sympt. Glutaraldehyde/HEMA products Recommended
Q8 Base/Q6 Sympt. Bonding agents recommended
Q8 Base/Q6 Sympt. Sealants recommended
Q8 Base/Q6 Sympt. Restorative treatments recommended
Q8 Base/Q6 Sympt. Lasers recommended
Q8 Base/Q6 Sympt. Oxalates recommended
Q8 Base/Q6 Sympt. No treatment recommended
Q8 Base/Q6 Sympt. Advice given (checked)
Q8 Base/Q6 Sympt. Stop product, habit and/or behavior (checked)
Q8 Base/Q6 Sympt. Decrease product, habit and/or behavior (checked)
Q8 Base/Q6 Sympt. Start or increase behavior (checked)
Q8 Base/Q6 Sympt. Other treatment recommended/prescribed (checked)
Q9 Base/Q7 Sympt. Recommended follow-up time for sensitive tooth/teeth
Month of visit
Year of visit