Republic of the Philippines

DEPARTMENT OF EDUCATION
Region XII Latest 1
Division of Sultan Kudarat 1/2 x 1 1/2

DENTAL HEALTH RECORD picture

Name: GENESIS O. DAVID 01/30/17

Date
Age: 12 Sex: FEMALE Birthdate: 02/13/2004
Event: SEPAKTAKRAW
Parent/Guardian ARIEL E. DAVID
:
Coach: APRIL JOY G. LOBO
CONDITION AND TREATMENT NEEDS GINGIVITIS
CONDITION PERIODONTAL
RIGHT 5 5 5 5 5 6 6 6 6 6 LEFT DISEASE
5 4 3 2 1 1 2 3 4 5
TEMPORARY TEETH MALOCCLUSION
SUPERNUMERA
RY TOOTH
1 1 1 1 1 1 1 11 2 2 2 2 2 2 2 2 RETAINED
8 7 6 5 4 3 2 1 2 3 4 5 6 7 8
PERMANENT DECIDOUS
TEETH DECUBITAL ULCER
4 4 4 4 4 4 4 4 3 3 3 3 3 3 3 3 CALCULUS
8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8
CONDITION CLEFT PALATE
TREATMENT ROOT FRAGMENT
TEMPORARY TEETH NEEDS FLUOROSIS
RIGHT 8 8 8 8 8 7 7 7 7 7 LEFT OTHERS (Specify)
5 4 3 2 1 1 2 3 4 5
CONDITION

YEAR LEVEL REMARKS DATE OF VISIT

DATE TEMPORARY TEETH
EXAMINATION INDEX D.F.T.
SEALANT (GI) NO. T/DECAYED
PERMANENT FILLING NO.T/FILLED
ART TOTAL D.F.T.
EXTRACTION
ORAL PROPHYLAXIS TEMPORARY TEETH
REFERRAL INDEX D.F.T.
OTHER ORAL TREATMENT NO. T/DECAYED
NO. T/MISSING
NO.T/FILLED
TOTAL D.F.T.
TOTAL SOUND TEETH
SYMBOLS FOR MOUTH EXAMINATION SYMBOLS FOR ACCOMPLISHMENT
X TOOTH INDICATED FOR EXTRACTION DU DECUBITAL ULCER XT - EXTRACTED PERMANENT TOOTH
F TOOTH INDICATED FOR FILLING MAL MALOCLUSSION Xt - EXTRACTED TEMPORARY TOOTH
HEAVY TOOTH WITH TEMPORARY FLU FLUOROSIS Am - AMALGAM FILLING
SHADE FILLING Gn NORMAL Com - COMPOSITE
RC RECURRENT CARIES Gm MODERATE GINGIVITIS
RF ROOT FRAGMENT (1-2 QUADRANTS) ARTIFICIAL RESTORATION
M MISSING TOOTH Gs SEVERE GINGIVITIS JC - JACKET CROWN
(3-4 QUADRANTS) I - INLAY
CMR COMPLETE MOUTH REHAB OP - ORAL PROPHYLAXIS
() SOUND ERUPTED PERMANENT ZOE ZINC OXIDE UEGENOL FILLNG
TF - TEMPORARY FILLING
R - REFERRED TO PRIVATE DENTIST
UN - ENERUPTED TOOTH
Division Meet Remarks/Finding:
_____________________________________ ____________________________________________________________________
DENTIST ____________________________________________________________________
(signature over printed name) ____________________________________________________________________
PRC: LICENSE: Date Examined:
Regional Meet Remarks/Finding:
_____________________________________ ____________________________________________________________________
DENTIST ____________________________________________________________________
(signature over printed name) ____________________________________________________________________
PRC: LICENSE: Date Examined:
PalarongPambansa Remarks/Finding:
_____________________________________ ____________________________________________________________________
DENTIST ____________________________________________________________________
(signature over printed name) ____________________________________________________________________
PRC: LICENSE: Date Examined: