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    Dental Health Record

    Uploaded by

    Nikki Cadiao
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    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd

    Dental Health Record

    Uploaded by

    Nikki Cadiao
    13 views2 pages
    -

    Original Title

    Dental-Health-Record

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    © © All Rights Reserved

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    Copyright:

    © All Rights Reserved
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    Download as docx, pdf, or txt
    13 views2 pages

    Dental Health Record

    Uploaded by

    Nikki Cadiao
    -

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
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    Revised as of February 2024

    Republic of the Philippines

    DEPARTMENT OF EDUCATION
    REGION VI
    VICTORIAS CITY
    Latest 1.8 inches x 1.4 inches
    picture

    DENTAL HEALTH RECORD


    Name:
    Age: Sex: Birth Date:

    Event:
    Parent/Guardian:

    CONDITION AND TREATMENT NEEDS


    CONDITION
    RIGHT
    TEMPORARY TEETH
    55 54 53 52 51 61 62 63 64 65 LEFT

    18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28

    PERMANENT TEETH
    48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38

    CONDITION
    TEMPORARY TEETH TREATMENT NEEDS
    85 84 83 82 81 71 72 73 74 75 LEFT
    RIGHT

    CONDITION

    YEAR LEVEL REMARKS


    DATE
    EXAMINATION
    SEALANT (GI)
    PERMANENT FILLING
    ART
    EXTRACTION
    ORAL PROPHYLAXIS
    REFERRAL
    OTHER ORAL
    TREATMENT
    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
    District Meet Remarks/Findings:
    WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
    DENTIST YES NO YES NO
    (signature over printed name) QUALIFIED TO PARTICiPATE:
    PRC: LICENSE: PTR# Date Examined: YES NO
    Division Meet Remarks/Findings:
    WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
    DENTIST YES NO YES NO
    (signature over printed name) QUALIFIED TO PARTICIPATE:
    PRC: LICENSE: PTR# Date Examined: YES NO
    Regional Meet Remarks/Findings:
    WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
    DENTIST YES NO YES NO
    (signature over printed name) QUALIFIED TO PARTCIPATE:
    PRC: LICENSE: PTR# Date Examined: YES NO
    Palarong Pambansa Remarks/Findings:
    WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
    DENTIST YES NO YES NO
    (signature over printed name) QUALIFIED TO PARTICIPATE:
    PRC: LICENSE: PTR# Date Examined: YES NO

    FOR SCHOOL SPORTS-FOR ELEMENTARY ATHLETE ONLY (Lower Meet up to Palarong Pambansa)

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