false
125
Endodontic exam & eval
ExamSheet
11
Microsoft Sans Serif
850
1100
false
2
false
false
48911
125
CheckBox
misc
0
false
92
1491
13
13
None
false
0
Left
false
-16777216
false
49703
125
StaticText
N
11
Microsoft Sans Serif
false
343
511
15
17
None
false
0
Left
false
-16777216
false
48910
125
CheckBox
misc
0
false
91
1451
13
13
None
false
0
Left
false
-16777216
false
48909
125
CheckBox
misc
0
false
91
1407
13
13
None
false
0
Left
false
-16777216
false
48908
125
CheckBox
misc
0
false
91
1363
13
13
None
false
0
Left
false
-16777216
false
48907
125
CheckBox
misc
0
false
91
1318
13
13
None
false
0
Left
false
-16777216
false
48906
125
CheckBox
misc
0
false
91
1273
13
13
None
false
0
Left
false
-16777216
false
48905
125
CheckBox
misc
0
false
91
1228
13
13
None
false
0
Left
false
-16777216
false
48904
125
CheckBox
misc
0
false
91
1186
13
13
None
false
0
Left
false
-16777216
false
48899
125
StaticText
Not 2nd or 3 rd molar.
11
Microsoft Sans Serif
false
115
1449
200
20
None
false
0
Left
false
-16777216
false
48903
125
InputField
misc
11
Microsoft Sans Serif
false
521
88
50
20
None
false
0
toothNum
Left
false
-16777216
false
49702
125
Rectangle
0
false
323
512
15
15
None
false
0
Left
false
-16777216
false
48901
125
StaticText
Less than 3 RCT for all teeth last 36 months (3 years).
11
Microsoft Sans Serif
false
115
1489
370
20
None
false
0
Left
false
-16777216
false
48900
125
Rectangle
0
false
91
1489
15
15
None
false
0
Left
false
-16777216
false
48898
125
Rectangle
0
false
90
1449
15
15
None
false
0
Left
false
-16777216
false
48897
125
StaticText
Does not require any additional dental treatment such as crown lengthening, root resectioning or orthodontic treatment
11
Microsoft Sans Serif
false
115
1405
600
40
None
false
0
Left
false
-16777216
false
48895
125
StaticText
MD space (vertically and horizontally) equivalent to that of the natural tooth with no loss of space due to caries or crowding
11
Microsoft Sans Serif
false
115
1361
600
40
None
false
0
Left
false
-16777216
false
48896
125
Rectangle
0
false
90
1405
15
15
None
false
0
Left
false
-16777216
false
48884
125
OutputText
sheet.DateTimeSheet
12
Microsoft Sans Serif
false
350
125
150
20
None
false
0
Left
false
-16777216
false
48885
125
StaticText
Endodontic diagnosis for tooth
12
Microsoft Sans Serif
true
260
88
260
20
None
false
0
Left
false
-16777216
false
48886
125
Rectangle
0
false
90
1184
15
15
None
false
0
Left
false
-16777216
false
48887
125
StaticText
Comprehensive Tx plan done
11
Microsoft Sans Serif
false
115
1184
200
20
None
false
0
Left
false
-16777216
false
48888
125
Rectangle
0
false
90
1226
15
15
None
false
0
Left
false
-16777216
false
48889
125
StaticText
Adequate periodontal support, based on alveolar bone levels (crown to root ratio of at least 1:1) visible on submitted radiographs with absence of furcation involvement).
11
Microsoft Sans Serif
false
115
1226
600
40
None
false
0
Left
false
-16777216
false
48890
125
StaticText
Absence of active periodontal disease.
11
Microsoft Sans Serif
false
115
1270
300
20
None
false
0
Left
false
-16777216
false
48891
125
Rectangle
0
false
90
1271
15
15
None
false
0
Left
false
-16777216
false
48892
125
Rectangle
0
false
90
1316
15
15
None
false
0
Left
false
-16777216
false
48893
125
StaticText
Adequate remaining non-diseased tooth structure to ensure that biologic width (3 mm) can be maintained during restoration
11
Microsoft Sans Serif
false
115
1317
600
40
None
false
0
Left
false
-16777216
false
48894
125
Rectangle
0
false
90
1361
15
15
None
false
0
Left
false
-16777216
false
49667
125
StaticText
Selective anesthesia:
11
Microsoft Sans Serif
false
447
545
145
17
None
false
0
Left
false
-16777216
false
49666
125
InputField
misc
11
Microsoft Sans Serif
false
593
545
195
17
None
false
0
Left
false
-16777216
false
49665
125
StaticText
Transillumination:
11
Microsoft Sans Serif
false
88
545
123
17
None
false
0
Left
false
-16777216
false
49664
125
InputField
misc
11
Microsoft Sans Serif
false
211
545
195
17
None
false
0
Left
false
-16777216
false
49663
125
StaticText
Condensing Osteitis
11
Microsoft Sans Serif
false
523
749
140
17
None
false
0
Left
false
-16777216
false
49662
125
Rectangle
0
false
663
755
15
15
None
false
0
Left
false
-16777216
false
49660
125
Rectangle
0
false
189
818
15
15
None
false
0
Left
false
-16777216
false
49659
125
CheckBox
misc
0
false
190
820
13
13
None
false
0
Left
false
-16777216
false
49658
125
CheckBox
misc
0
false
529
855
13
13
None
false
0
Left
false
-16777216
false
49657
125
Rectangle
0
false
528
853
15
15
None
false
0
Left
false
-16777216
false
49656
125
CheckBox
misc
0
false
342
856
13
13
None
false
0
Left
false
-16777216
false
49655
125
Rectangle
0
false
341
854
15
15
None
false
0
Left
false
-16777216
false
49654
125
StaticText
NIHB Eligibility (Restorability) Assessment
12
Microsoft Sans Serif
true
302
1092
370
20
None
false
0
Left
false
-16777216
false
49653
125
CheckBox
misc
0
false
416
838
13
13
None
false
0
Left
false
-16777216
false
49652
125
Rectangle
0
false
415
836
15
15
None
false
0
Left
false
-16777216
false
49651
125
CheckBox
misc
0
false
217
838
13
13
None
false
0
Left
false
-16777216
false
49650
125
Rectangle
0
false
216
836
15
15
None
false
0
Left
false
-16777216
false
49649
125
CheckBox
misc
0
false
603
735
13
13
None
Apical diagnoses
true
0
Left
false
-16777216
false
49648
125
Rectangle
0
false
602
733
15
15
None
false
0
Left
false
-16777216
false
49647
125
Rectangle
0
false
524
819
15
15
None
false
0
Left
false
-16777216
false
49646
125
CheckBox
misc
0
false
525
821
13
13
None
false
0
Left
false
-16777216
false
49645
125
Rectangle
0
false
385
819
15
15
None
false
0
Left
false
-16777216
false
49644
125
CheckBox
misc
0
false
386
821
13
13
None
false
0
Left
false
-16777216
false
49643
125
CheckBox
misc
0
false
210
855
13
13
None
false
0
Left
false
-16777216
false
49642
125
Rectangle
0
false
209
853
15
15
None
false
0
Left
false
-16777216
false
49661
125
CheckBox
misc
0
false
664
757
13
13
None
Apical diagnoses
true
0
Left
false
-16777216
false
49641
125
InputField
misc
11
Microsoft Sans Serif
false
145
377
644
17
None
false
0
Left
false
-16777216
false
49640
125
Rectangle
0
false
470
631
15
15
None
false
0
Left
false
-16777216
false
49699
125
CheckBox
misc
0
false
359
514
13
13
None
false
0
Left
false
-16777216
false
49639
125
CheckBox
misc
0
false
471
633
13
13
None
Pulpal diagnoses
true
0
Left
false
-16777216
false
49700
125
CheckBox
misc
0
false
324
514
13
13
None
false
0
Left
false
-16777216
false
49636
125
Rectangle
0
false
179
614
15
15
None
false
0
Left
false
-16777216
false
49635
125
CheckBox
misc
0
false
180
616
13
13
None
Pulpal diagnoses
true
0
Left
false
-16777216
false
49633
125
Rectangle
0
false
642
614
15
15
None
false
0
Left
false
-16777216
false
49634
125
CheckBox
misc
0
false
643
616
13
13
None
Pulpal diagnoses
true
0
Left
false
-16777216
false
49632
125
InputField
misc
11
Microsoft Sans Serif
false
228
528
560
17
None
false
0
Left
false
-16777216
false
49631
125
CheckBox
misc
0
false
250
752
13
13
None
Apical diagnoses
true
0
Left
false
-16777216
false
49630
125
Rectangle
0
false
249
750
15
15
None
false
0
Left
false
-16777216
false
49629
125
Rectangle
0
false
309
733
15
15
None
false
0
Left
false
-16777216
false
49628
125
CheckBox
misc
0
false
310
735
13
13
None
Apical diagnoses
true
0
Left
false
-16777216
false
49627
125
Rectangle
0
false
266
495
15
15
None
false
0
Left
false
-16777216
false
49626
125
CheckBox
misc
0
false
267
497
13
13
None
false
0
Left
false
-16777216
false
49625
125
InputField
misc
11
Microsoft Sans Serif
false
572
494
217
17
None
false
0
Left
false
-16777216
false
49624
125
StaticText
Thin root
11
Microsoft Sans Serif
false
273
852
67
17
None
false
0
Left
false
-16777216
false
49623
125
CheckBox
misc
0
false
363
616
13
13
None
Pulpal diagnoses
true
0
Left
false
-16777216
false
49622
125
Rectangle
0
false
362
614
15
15
None
false
0
Left
false
-16777216
false
49621
125
Rectangle
0
false
244
716
15
15
None
false
0
Left
false
-16777216
false
49620
125
CheckBox
misc
0
false
245
718
13
13
None
Apical diagnoses
true
0
Left
false
-16777216
false
49619
125
CheckBox
misc
0
false
361
346
13
13
None
false
0
Left
false
-16777216
false
49618
125
Rectangle
0
false
360
344
15
15
None
false
0
Left
false
-16777216
false
49617
125
Rectangle
0
false
465
750
15
15
None
false
0
Left
false
-16777216
false
49616
125
CheckBox
misc
0
false
466
752
13
13
None
Apical diagnoses
true
0
Left
false
-16777216
false
49615
125
Rectangle
0
false
219
648
15
15
None
false
0
Left
false
-16777216
false
49614
125
CheckBox
misc
0
false
220
650
13
13
None
Pulpal diagnoses
true
0
Left
false
-16777216
false
49613
125
Rectangle
0
false
459
648
15
15
None
false
0
Left
false
-16777216
false
49612
125
CheckBox
misc
0
false
460
650
13
13
None
Pulpal diagnoses
true
0
Left
false
-16777216
false
49611
125
InputField
misc
11
Microsoft Sans Serif
false
358
394
431
17
None
false
0
Left
false
-16777216
false
49610
125
Rectangle
0
false
221
344
15
15
None
false
0
Left
false
-16777216
false
49609
125
CheckBox
misc
0
false
222
346
13
13
None
false
0
Left
false
-16777216
false
49608
125
CheckBox
misc
0
false
320
633
13
13
None
Pulpal diagnoses
true
0
Left
false
-16777216
false
49607
125
Rectangle
0
false
319
631
15
15
None
false
0
Left
false
-16777216
false
49701
125
Rectangle
0
false
358
512
15
15
None
false
0
Left
false
-16777216
false
49604
125
InputField
misc
11
Microsoft Sans Serif
false
340
360
449
17
None
false
0
Left
false
-16777216
false
49601
125
StaticText
Previously Treated
11
Microsoft Sans Serif
false
88
647
130
17
None
false
0
Left
false
-16777216
false
49600
125
StaticText
Pulp Necrosis
11
Microsoft Sans Serif
false
369
630
100
17
None
false
0
Left
false
-16777216
false
49599
125
StaticText
Asymptomatic Irreversible Pulpitis
11
Microsoft Sans Serif
false
88
630
230
17
None
false
0
Left
false
-16777216
false
49598
125
StaticText
Normal Apical Tissues
11
Microsoft Sans Serif
false
88
715
155
17
None
false
0
Left
false
-16777216
false
49597
125
StaticText
Apical Diagnoses
11
Microsoft Sans Serif
true
88
698
135
17
None
false
0
Left
false
-16777216
false
49596
125
StaticText
Previously Initiated Therapy
11
Microsoft Sans Serif
false
271
647
187
17
None
false
0
Left
false
-16777216
false
49595
125
StaticText
Pulps Diagnoses
11
Microsoft Sans Serif
true
88
596
130
17
None
false
0
Left
false
-16777216
false
49594
125
StaticText
Other diagnoses/findings
11
Microsoft Sans Serif
true
88
800
195
17
None
false
0
Left
false
-16777216
false
49593
125
StaticText
Restorations (defective, newly placed?):
11
Microsoft Sans Serif
false
90
394
268
17
None
false
0
Left
false
-16777216
false
49592
125
StaticText
Reversible pulpitis
11
Microsoft Sans Serif
false
231
613
130
17
None
false
0
Left
false
-16777216
false
49591
125
StaticText
Symptomatic Irreversible Pulpitis
11
Microsoft Sans Serif
false
418
613
223
17
None
false
0
Left
false
-16777216
false
49590
125
StaticText
Normal Pulp
11
Microsoft Sans Serif
false
88
613
90
17
None
false
0
Left
false
-16777216
false
49589
125
StaticText
Percussion
11
Microsoft Sans Serif
false
226
511
82
17
None
false
0
Left
false
-16777216
false
49588
125
StaticText
Palpation
11
Microsoft Sans Serif
false
392
511
71
17
None
false
0
Left
false
-16777216
false
49587
125
StaticText
Tooth Sleuth (biting):
11
Microsoft Sans Serif
false
88
528
140
17
None
false
0
Left
false
-16777216
false
49586
125
StaticText
Periapical tests
11
Microsoft Sans Serif
true
88
511
120
17
None
false
0
Left
false
-16777216
false
49585
125
StaticText
Cold
11
Microsoft Sans Serif
false
214
494
37
17
None
false
0
Left
false
-16777216
false
49584
125
StaticText
Electric pulp test:
11
Microsoft Sans Serif
false
452
494
120
17
None
false
0
Left
false
-16777216
false
49583
125
StaticText
Heat
11
Microsoft Sans Serif
false
335
494
37
17
None
false
0
Left
false
-16777216
false
49582
125
StaticText
Periodontal status (probing, mobility):
11
Microsoft Sans Serif
false
90
360
250
17
None
false
0
Left
false
-16777216
false
49581
125
StaticText
Caries:
11
Microsoft Sans Serif
false
90
377
55
17
None
false
0
Left
false
-16777216
false
49580
125
InputField
misc
11
Microsoft Sans Serif
false
90
226
700
68
None
false
0
Left
false
-16777216
false
49579
125
StaticText
Soft tissue:
11
Microsoft Sans Serif
false
424
343
80
17
None
false
0
Left
false
-16777216
false
49578
125
StaticText
Clinical exam
11
Microsoft Sans Serif
true
90
326
100
17
None
false
0
Left
false
-16777216
false
49577
125
StaticText
Facial asymmetry
11
Microsoft Sans Serif
false
90
343
130
17
None
false
0
Left
false
-16777216
false
49576
125
StaticText
Sinus tract
11
Microsoft Sans Serif
false
279
343
80
17
None
false
0
Left
false
-16777216
false
49575
125
StaticText
Pulp tests
11
Microsoft Sans Serif
true
88
494
100
17
None
false
0
Left
false
-16777216
false
49574
125
InputField
misc
11
Microsoft Sans Serif
false
504
343
285
17
None
false
0
Left
false
-16777216
false
49573
125
StaticText
Open apex
11
Microsoft Sans Serif
false
444
818
79
17
None
false
0
Left
false
-16777216
false
49572
125
StaticText
Pulpo lithiasis
11
Microsoft Sans Serif
false
88
817
100
17
None
false
0
Left
false
-16777216
false
49571
125
StaticText
Acute Apical Abscess
11
Microsoft Sans Serif
false
316
749
148
17
None
false
0
Left
false
-16777216
false
49570
125
StaticText
Asymptomatic Apical Periodontitis
11
Microsoft Sans Serif
false
371
732
230
17
None
false
0
Left
false
-16777216
false
49569
125
StaticText
Symptomatic Apical Periodontitis
11
Microsoft Sans Serif
false
88
732
220
17
None
false
0
Left
false
-16777216
false
49568
125
StaticText
Chronic Apical Abscess
11
Microsoft Sans Serif
false
88
749
160
17
None
false
0
Left
false
-16777216
false
49567
125
StaticText
Hypercementosis
11
Microsoft Sans Serif
false
407
852
120
17
None
false
0
Left
false
-16777216
false
49566
125
StaticText
Chief complaint
11
Microsoft Sans Serif
true
90
209
125
17
None
false
0
Left
false
-16777216
false
49565
125
StaticText
Clinical testing
11
Microsoft Sans Serif
true
88
477
125
17
None
false
0
Left
false
-16777216
false
49564
125
StaticText
External resorption
11
Microsoft Sans Serif
false
282
835
132
17
None
false
0
Left
false
-16777216
false
49563
125
StaticText
Root dilaceration
11
Microsoft Sans Serif
false
88
851
120
17
None
false
0
Left
false
-16777216
false
49562
125
StaticText
Pulpal obliteration
11
Microsoft Sans Serif
false
260
818
124
17
None
false
0
Left
false
-16777216
false
49561
125
StaticText
Internal resorption
11
Microsoft Sans Serif
false
88
834
127
17
None
false
0
Left
false
-16777216
false
49677
125
StaticText
Y
11
Microsoft Sans Serif
false
251
494
14
17
None
false
0
Left
false
-16777216
false
49675
125
StaticText
Additional notes:
11
Microsoft Sans Serif
false
90
411
114
17
None
false
0
Left
false
-16777216
false
49676
125
InputField
misc
11
Microsoft Sans Serif
false
204
411
585
34
None
false
0
Left
false
-16777216
false
49684
125
CheckBox
misc
0
false
302
497
13
13
None
false
0
Left
false
-16777216
false
49685
125
Rectangle
0
false
301
495
15
15
None
false
0
Left
false
-16777216
false
49698
125
StaticText
N
11
Microsoft Sans Serif
false
286
494
15
17
None
false
0
Left
false
-16777216
false
49704
125
StaticText
Y
11
Microsoft Sans Serif
false
308
511
14
17
None
false
0
Left
false
-16777216
false
49705
125
StaticText
N
11
Microsoft Sans Serif
false
498
511
15
17
None
false
0
Left
false
-16777216
false
49706
125
StaticText
Y
11
Microsoft Sans Serif
false
463
511
14
17
None
false
0
Left
false
-16777216
false
49707
125
Rectangle
0
false
513
512
15
15
None
false
0
Left
false
-16777216
false
49708
125
CheckBox
misc
0
false
479
514
13
13
None
false
0
Left
false
-16777216
false
49709
125
Rectangle
0
false
478
512
15
15
None
false
0
Left
false
-16777216
false
49710
125
CheckBox
misc
0
false
514
514
13
13
None
false
0
Left
false
-16777216
false
49711
125
Rectangle
0
false
387
495
15
15
None
false
0
Left
false
-16777216
false
49712
125
StaticText
Y
11
Microsoft Sans Serif
false
372
494
14
17
None
false
0
Left
false
-16777216
false
49713
125
CheckBox
misc
0
false
423
497
13
13
None
false
0
Left
false
-16777216
false
49714
125
StaticText
N
11
Microsoft Sans Serif
false
407
494
15
17
None
false
0
Left
false
-16777216
false
49715
125
CheckBox
misc
0
false
388
497
13
13
None
false
0
Left
false
-16777216
false
49716
125
Rectangle
0
false
422
495
15
15
None
false
0
Left
false
-16777216