Republic of the Philippines

Department of Education
Region 02
Latest 1 x 1
DIVISION OF ISABELA picture
DENTAL HEALTH RECORD
(with name tag)
Date
Name:
Last First Ext. Name (e.g.Jr.Sr.III) M.I.

Age: Sex: Date of Birth:

mm dd yy
Event:
Parent/Guardian:
Coach:

GINGIVITIS
CONDITION AND TREATMENT NEEDS PRERIODICAL
CONDITION DISEASE
RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT MALOCCLUSION
TEMPORARY
TEETH SUPERNUMERARY
TOOTH
RETAINED
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 DECIDOUS TEETH
DECUBITAL ULCER
PERMANENT
TEETH CALCULUS
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CLEFT PALATE
CONDITION ROOT FRAGMENT
TREATMENT
NEEDS FLUOROSIS
TEMPORARY
TEETH OTHERS (Specify)
85 84 83 82 81 71 72 73 74 75 LEFT
RIGHT
CONDITION DATE OF VISIT
YEAR LEVEL REMARKS TEMPORARY TEETH
DATE INDEX D.F.T.
EXAMINATION SYMBOLS FOR MOUTH EXAMINATION NO. TSYMBOLS
/DECAYED
FOR ACCOMPLISHMENT
SEALANT (GI) X - TOOTH INDICATED DU - DECUBITAL ULCER NO. T/ FILLED
Xt - EXTRACTED PERMANENT TOOTH
FOR EXTRACTION MAL - MALOCLUSSION xt - EXTRACTED TEMPORARY TOOTH
PERMANENT FILLING
F - TOOTH INDICATED FLU - FLOUROSIS
TOTAL D.F.T.
Am - AMALGAM FILLING
ART FOR FILLING Gn - NORMAL PERMANENT
Com TEETH
- COMPOSITE FILLING
HEAVY SHADE - TOOTH WITH TEMPORARY Gm - MODERATE GINGIVITIS
EXTRACTION INDEX D.F.T.
FILLING (1-2 QUADRANTS) ARTIFICIAL RESTORATION
RC -
ORAL PROPHYLAXIS RECURRENT CARIES Gs - SEVERE GINGIVITIS NO. T /DECAYED
JC - JACKET CROWN
RF - ROOT FRAGMENT (3-4 QUADRANTS)
REFERRAL NO. T/ MISSING
I - INLAY
M - MISSING TOOTH CMR - COMPLETE MOUTH REHAB OP - ORAL PROPHYLAXIS
OTHER ORAL TREATMENT () - SOUND ERUPTED PERMANENT NO. T/ FILLED
ZOE - ZINC OXIDE UEGENOL FILLING
TOOTH TOTAL D.F.T.
TF - TEMPORARY FILLING
TOTAL SOUND
R - TEETH
REFERRED TO PRIVATE DENTIST
UN - UNERUPTED

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: