Revascularization Study - Post Treatment Follow-up Findings
POST TREATMENT FOLLOW-UP FINDINGS
This form is for entering information from a follow-up appointment for a case in which you have already submitted the initial information. It is critical that you match the "Case ID" for the original information.
If you are looking to enter a new case exit this form and go to:
http://aae1.revasc.sgizmo.com
Note:
Do to page logic do not use your browser's "Back" button. If you need to edit information already entered, contact Dr. Ed Halteman,
ed@survey-design-and-analysis.com
.
1.
Please enter the case ID from the case to which this follow-up relates. The case ID consists of your initials followed by a three-digit number representing which case you are entering:
(your first case was 001, your second 002, etc.) (E.g. ASL001)
2.
Please provide the patient's initials for this case.
(leave blank if unknown)
First and Last Initials
3.
Please indicate the time frame for this follow-up appointment:
-- Please Select --
<3 months
3-6 months
7-12 months
13-18 months
19-24 months
>24 months
4.
Please indicate the level of spontaneous pain the patient was experiencing for this follow-up?
No pain
Mild pain
Moderate pain
Severe pain
Uncertain/Not applicable
5.
Please indicate whether any of the following were present for this follow-up.
(Select all that apply)
Swelling near or around the tooth
Sinus tract draining infection (stemming from the tooth)
Mobility (> 2mm)
None of these
6.
Please indicate the pulp responsiveness for all applicable tests performed for the tooth in question.
Response
No response
Not performed
Cold
Heat
EPT
7.
Please indicate the degree to which the patient reported tenderness to percussion.
No tenderness
Mild tenderness
Moderate tenderness
Severe tenderness
No test performed