Indian Dental Academy: will be one of the most relevant and exciting training center with best faculty and flexible training programs for dental professionals who wish to advance in their dental practice,Offers certified courses in Dental implants,Orthodontics,Endodontics,Cosmetic Dentistry, Prosthetic Dentistry, Periodontics and General Dentistry.

1. Serial No.__________
i) General Information
Name: Address:
Sex/Age: M/F_____
Family Income: Regular/Seasonal/Daily Literary status:
No. of members: Occupation:
ii) Any Complaint:
iii) Method and frequency of cleaning the teeth
iv) Reason for loss of tooth / teeth
Caries / Periodontal disease / Trauma / Others.
v) Dentition Status
Teeth present and Teeth missing
Maxillary
7 6 5 4 3 2 1 1 2 3 4 5 6 7
Mandibular
7 6 5 4 3 2 1 1 2 3 4 5 6 7
X – Missing
0 – Not replaced
1 – Replaced with removable partial denture
2 – Replaced with fixed partial denture
3 – Implant
vi) Complaint with the prosthesis
(0) No complaint (4) Functional + Esthetic problem
(1) Functional problem (5) Functional+ Esthetic+Biologic
(2) Esthetic problem (6) Biological + Esthetic
(3) Biologic problem (7) Biological + Functional
vii) Classification of Edentulous arches
Class I mod ______ Class III mod _______
Class II mod ______ Class IV __________
Loss of teeth since ________ Years ________ Months
viii) Prosthetic need Maxillary Mandibular
0 – No prosthesis needed
1 – Need for RPD
2 – Need for FPD
ix) Reason for not undergoing treatment
(1) Lack of awareness
(2) Cost factor
(3) Availability
(4) Fear of Dental Treatment
(5) Time factor
PROFORMA