LYNBROOK SMILES - SOAP Form - Initial Consult & Oral Exam for OAT

Initial SOAP for Oral Appliance Therapy
Patient Name

First NameLast Name
Patient Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Patient Email Address
example@example.com
General Dental Fitness

Indicate if the patient presents with any of the following:

Rows	Yes	No	Comments (if marked Yes)
Periodontal disease or decay
Active TMJ or Joint Disorder
Reconstruction in mandible opening
Protrusion of jaw
Fewer than 10 teeth in either arch
Severe bruxism
Upcoming dental work needed

When did the patient last have dental X-rays taken?

MonthDayYear
2 digit month, 2 digit day, 4 digit year
History & Examination

Indicate if the patient has had any of the following:

Rows	Yes	No	Comments (if marked Yes)
Injury to head or neck
Injury to face
Injury to teeth
Adenoids removed
Tonsils removed
Jaw joint surgery
Orthognarthic surgery
Removal of third molar
Ear, nose, or throat surgery
Other oral surgery
Any teeth lost or removed

Has the patient had any jaw pain in the last 30 days?
If they have had jaw pain, where does the patient experience the pain?
If they have had jaw pain, how long does it last?

Measurements of Mandibular Ranges of Motion (Normal ranges of motion based on cranial skeletal types are: 42-52 mm maximum opening, 8-12 mm protrusive, and 10-14 mm of lateral movement both right and left)

Rows	mm
Maximum opening
Maximum protrusion
Maximum right lateral excursion
Maximum left lateral excursion
Deviation to the right
Deviation to the left
Overbite
Overjet
Dental midline

Classification of the bite (occlusion)
How would you rate the dental crowding?
How would you rate the dental spacing?

Degree of of hypertrophy of pharyngeal tonsils

Rows	0	1	2	3	4
Left-category
Right-category

Grading of pharyngeal obstruction

Rows	I	II	III	IV
Left-category
Right-category

Please indicate Mallampati grading
Uvula observations:
Soft palate observations:
Tongue observations:
Maxilla - level of hard palate
Mandible
Any other observations?
Has the patient had a sleep study?

Has the patient previously been treated for sleep apnea?

Rows	Never	Current	Past
CPAP
Oral Appliance
Surgery
Hypoglossal Nerve Stimulation
GLP-1 or Other Medication

Is the patient suitable for an oral appliance?
If suitable for an oral appliance, which type is recommended?
Examining Dentist's Name:
Dentist Signature:
Date of Exam:

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Should be Empty:

Initial SOAP for Oral Appliance Therapy

General Dental Fitness

History & Examination