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Free Oral Assessment Tool Form - PDF Form Download

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Download and use this Oral Assessment Tool for your patients.

Oral Assessment Tool Form


Text Version of the Form

ORAL ASSESSMENT TOOL

PATIENT NAME ADMISSION # DATE

ORAL CAVITY

TEETH
DENTURES □ UPPER □ LOWER
PARTIAL □ UPPER □ LOWER

□ MISSING □ CARIOUS/BROKEN □ NO TEETH

APPEARANCE
LIPS

□ NORMAL □ DRY,CHAPPED □ WHITE/RED PATCHES
□ BLEEDING □ ULCERS □ OTHER ___________

TONGUE
□ NORMAL/COATED □ WHITE/RED PATCHES □ OTHER ___________
GUMS
□ NORMAL □ SWOLLEN □ BLEEDING □ FISSURED □ OTHER

CHEEK, FLOOR, AND ROOF OF MOUTH
□ NORMAL □ DRY □ RED □ SWOLLEN
□ WHITE/RED PATCHES □ OPEN SORES □ OTHER _____________________

ODOR NOTED □ YES □ NO

DEBRIS NOTED □ YES □ NO

FUNCTION

RESIDENT ABILITY TO EAT WITH FULL/PARTIAL DENTURES
□ GOOD □ FAIR □ POOR □ NA

RESIDENT REQUIRES ASSISTANCE WITH ORAL CARE □ YES □ NO
If yes, describe ______________________________________________

RESIDENT REQUIRES TOTAL ORAL CARE □ YES □ NO

DENTAL REFERRAL RECOMMENDED □ YES □ NO
NURSE PERFORMING ASSESSMENT __________________________________________

 

 

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