DIAGNOSTIC: 1 = NOT Comfortable or Proficient. 2 = Comfortable or Proficient. 3 = VERY Comfortable or Proficient.
DIRECTIONS: Select the corresponding number (1,2,3) that identifies your comfort and/or proficiency in each category.
Periodic Oral Examination
1
2
3
Limited Oral Examination
1
2
3
Comp oral evaluation new patient
1
2
3
Oral evaluation < 3 yrs. old
1
2
3
PREVENTATIVE: 1 = NOT Comfortable or Proficient. 2 = Comfortable or Proficient. 3 = VERY Comfortable or Proficient.
Sealants
1
2
3
Space Maint fixed unilateral
1
2
3
Space Maint fixed bilateral
1
2
3
Space Maint removal
1
2
3
Recementation space maint
1
2
3
RESTORATIVE: 1 = NOT Comfortable or Proficient. 2 = Comfortable or Proficient. 3 = VERY Comfortable or Proficient.
Amalgam 1 surface prim/perm
1
2
3
Amalgam 2 surfaces prim/perm
1
2
3
Amalgam 3 surfaces prim/perm
1
2
3
Amalgam 4+ surfaces prim/perm
1
2
3
Resin 1 surface anterior
1
2
3
Resin 2 surfaces anterior
1
2
3
Resin 3 surfaces anterior
1
2
3
Resin 4+ w/incisal angle anterior
1
2
3
Resin composite crown anterior
1
2
3
Resin 1 surface posterior
1
2
3
Resin 2 surfaces posterior
1
2
3
Resin 3 surfaces posterior
1
2
3
Resin 4+ surfaces posterior
1
2
3
COMPLETE DENTURES & PARTIALS: 1 = NOT Comfortable or Proficient. 2 = Comfortable or Proficient. 3 = VERY Comfortable or Proficient.
Complete denture maxillary
1
2
3
Complete denture mandibular
1
2
3
Immediate denture maxillary
1
2
3
Immediate denture mandibular
1
2
3
Maxillary partial resin base
1
2
3
Mandibular partial resin base
1
2
3
Maxillary partial metal base
1
2
3
Mandibular partial metal base
1
2
3
Flexible maxillary partial
1
2
3
Flexible mandibular partial
1
2
3
Adjust complete denture
1
2
3
Adjust partial denture
1
2
3
Chairside reline complete denture
1
2
3
ORAL SURGERY: 1 = NOT Comfortable or Proficient. 2 = Comfortable or Proficient. 3 = VERY Comfortable or Proficient.
Extraction anterior (simple)
1
2
3
Extraction anterior (surgical)
1
2
3
Extraction 3rd molars (simple)
1
2
3
Extraction 3rd molars (surgical)
1
2
3
Extraction partial bony impact
1
2
3
Extraction complete bony impact
1
2
3
Surgical removal resid tooth root
1
2
3
Alveoloplasty w/extract
1
2
3
Alveoloplasty w/o extract
1
2
3
Tori removal maxillary
1
2
3
Tori removal mandibular
1
2
3
CROWNS & BRIDGES: 1 = NOT Comfortable or Proficient. 2 = Comfortable or Proficient. 3 = VERY Comfortable or Proficient.
Crown resin (Indirect)
1
2
3
Crown PFM
1
2
3
Crown porcelain/ceramic
1
2
3
Recement crown
1
2
3
Prefab SSC primary
1
2
3
Prefab SSC permanent
1
2
3
Core build-up include any pins
1
2
3
Pin retention (+rest)
1
2
3
Cast post & core
1
2
3
Prefab post & core
1
2
3
ENDODONTICS: 1 = NOT Comfortable or Proficient. 2 = Comfortable or Proficient. 3 = VERY Comfortable or Proficient.
Pulp-cap direct
1
2
3
Pulp-cap indirect
1
2
3
Therapeutic pulp
1
2
3
Pulpal debridement
1
2
3
RCT Anterior
1
2
3
RCT Biscuspid
1
2
3
RCT Molar
1
2
3
Retreat RCT Anterior
1
2
3
Retreat RCT Bicuspid
1
2
3
Retreat RCT Molar
1
2
3
ADJUNCTIVE SERVICES: 1 = NOT Comfortable or Proficient. 2 = Comfortable or Proficient. 3 = VERY Comfortable or Proficient.
ER treatment
1
2
3
Nitrous oxide
1
2
3
Treat post comp
1
2
3
Removal ortho app
1
2
3
Occlusal guard
1
2
3
SPECIAL SKILLS: 1 = NOT Comfortable or Proficient. 2 = Comfortable or Proficient. 3 = VERY Comfortable or Proficient.
Pedo experience
1
2
3
Ages 0-5
1
2
3
Ages 6-11
1
2
3
Ages 12-18
1
2
3
OTHER: 1 = NOT Comfortable or Proficient. 2 = Comfortable or Proficient. 3 = VERY Comfortable or Proficient.
Fast paced office
1
2
3
Care calls
1
2
3
Medicaid experience
1
2
3
IV sedation
1
2
3
Oral sedation
1
2
3
Managing Medically Complex Pts
1
2
3
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