Republic of the Philippines

DEPARTMENT OF EDUCATION

Region

Division
Latest 1½ x 1½ picture

DENTAL HEALTH RECORD

Name:
Age: Sex Birth Date Date
Event:
Parent/Guardian: GINGIVITIS
Coach: PERIODONTAL
DISEASE
CONDITION AND TREATMENT NEEDS MALOCCLUSION
CONDITION SUPERNUMERAR
RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT Y TOOTH
TEMPORARY TEETH
RETAINED
DECIDOUS
DECUBITAL ULCER
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 CALCULUS
CLEFT PALATE
PERMANENT TEETH
ROOT FRAGMENT
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 FLUOROSIS
CONDITION
OTHERS (Specify)
TREATMENT NEEDS
TEMPORARY TEETH

RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT
DATE OF VISIT
CONDITION TEMPORARY TEETH
INDEX D.F.T.
YEAR LEVEL REMARKS NO. T /DECAYED
DATE NO. T/ FILLED
EXAMINATION TOTAL D.F.T.
SEALANT (GI)
PERMANENT FILLING PERMANENT TEETH
ART INDEX D.F.T.
EXTRACTION NO. T /DECAYED
ORAL PROPHYLAXIS NO. T/MISSING
REFERRAL NO. T/ FILLED
OTHER ORAL TREATMENT TOTAL D.F.T.
TOTAL SOUND TEETH

SYMBOLS FOR MOUTH EXAMINATION SYMBOLS FOR ACCOMPLISHMENT

X - TOOTH INDICATED DU - DECUBITAL ULCER XT - EXTRACTED PERMANENT TOOTH
FOR EXTRACTION MAL - MALOCLUSSION xt - EXTRACTED TEMPORARY TOOTH
F - TOOTH INDICATED FLU - FLUOROSIS Am - AMALGAM FILLING
FOR FILLING Gn - NORMAL Com - COMPOSITE FILLING
HEAVY - TOOTH WITH TEMPORARY Gm - MODERATE GINGIVITIS
SHADE FILLING (1-2 QUADRANTS) ARTIFICIAL RESTORATION
RC - RECURRENT CARIES Gs - SEVERE GINGIVITIS JC - JACKET CROWN
RF - ROOT FRAGMENT (3-4 QUADRANTS) I - INLAY
M - MISSING TOOTH CMR - COMPLETE MOUTH REHAB OP - ORAL PROPHYLAXIS
(√) - SOUND ERUPTED PERMANENT ZOE - ZINC OXIDE UEGENOL FILLING
TOOTH TF - TEMPORARY FILLING
R - REFERRED TO PRIVATE DENTIST
UN - UNERUPTED TOOTH

Division Meet Remarks/Findings:

DENTIST
(signature over printed name)
PRC: LICENSE: Date Examined:
Regional Meet Remarks/Findings:

DENTIST
(signature over printed name)
PRC: LICENSE: Date Examined:
Palarong Pambansa Remarks/Findings:

DENTIST
(signature over printed name)
PRC: LICENSE: Date Examined:
FOR PALARONG PAMBANSA ONLY