Periodontal Charting Form
Record non-sensitive patient and clinical periodontal assessment data for dental charting.
Patient Initials
*
Patient Gender
*
Male
Female
Other
Patient Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Date of Examination
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Dental Provider Name
*
Probing Depths (mm)
*
Rows
Tooth 1
Tooth 2
Tooth 3
Tooth 4
Tooth 5
Tooth 6
Mesial
Buccal
Distal
Bleeding on Probing
Rows
Tooth 1
Tooth 2
Tooth 3
Tooth 4
Tooth 5
Tooth 6
Mesial
1
2
3
4
5
6
Buccal
7
8
9
10
11
12
Distal
13
14
15
16
17
18
Gingival Recession (mm)
Rows
Tooth 1
Tooth 2
Tooth 3
Tooth 4
Tooth 5
Tooth 6
Mesial
Buccal
Distal
Furcation Involvement
Rows
Tooth 1
Tooth 2
Tooth 3
Tooth 4
Tooth 5
Tooth 6
Mesial
19
20
21
22
23
24
Buccal
25
26
27
28
29
30
Distal
31
32
33
34
35
36
Tooth Mobility (Grade)
Rows
Tooth 1
Tooth 2
Tooth 3
Tooth 4
Tooth 5
Tooth 6
Mobility
0
1
2
3
0
1
2
3
0
1
2
3
0
1
2
3
0
1
2
3
0
1
2
3
Submit Chart
Should be Empty: