DENTAL RECORD DENTAL RECORD

Name: ________________________________________________ Age: _______ Gender: _________ Name: ________________________________________________ Age: _______ Gender: _________
Address: ___________________________________________ Date of Birth: ___________________ Address: ___________________________________________ Date of Birth: ___________________
Course/Year Level: ___________________ Position/Department (for employees): __________________ Course/Year Level: ___________________ Position/Department (for employees): __________________
Medical History: Medical History:
Medical History: Medical History:
Hypertension Epilepsy Allergies Hypertension Epilepsy Allergies
Diabetes Bleeding Disorder Others: Diabetes Bleeding Disorder Others:
Cardio Vascular Dis. Asthma Cardio Vascular Dis. Asthma

DEFINITION STATUS INDEX : DMFT DEFINITION STATUS INDEX : DMFT

No. of T Decayed X- No. of T Decayed X-

Status Status
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 F- 18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 F-
No. Of T Missing No. Of T Missing

No. of T Filled No. of T Filled

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

Status Status

DENTAL RECORD DENTAL RECORD

Name: ________________________________________________ Age: _______ Gender: _________ Name: ________________________________________________ Age: _______ Gender: _________
Address: ___________________________________________ Date of Birth: ___________________ Address: ___________________________________________ Date of Birth: ___________________
Course/Year Level: ___________________ Position/Department (for employees): __________________ Course/Year Level: ___________________ Position/Department (for employees): __________________
Medical History: Medical History:
Medical History: Medical History:
Hypertension Epilepsy Allergies Hypertension Epilepsy Allergies
Diabetes Bleeding Disorder Others: Diabetes Bleeding Disorder Others:
Cardio Vascular Dis. Asthma Cardio Vascular Dis. Asthma

DEFINITION STATUS INDEX : DMFT DEFINITION STATUS INDEX : DMFT

No. of T Decayed X- No. of T Decayed X-

Status Status
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 F- 18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 F-
No. Of T Missing No. Of T Missing

No. of T Filled No. of T Filled

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

Status Status
 TREATMENT RECORD TREATMENT RECORD

TOOTH NATURE OF TOOTH NATURE OF

DATE TREATMENT REMARKS DATE TREATMENT REMARKS
NO. OPERATION NO. OPERATION

Period Condition: DENTAL PROSTESIS Period Condition: DENTAL PROSTESIS

Normal Denture Wearer: Y N Remarks: __________________ Normal Denture Wearer: Y N Remarks: __________________

Gingivitis Please Specify: Gingivitis Please Specify:

Periodontal Disease Need for Denture: Y N Remarks: __________________ Periodontal Disease Need for Denture: Y N Remarks: __________________

Other Abnormal Conditions Please Specify: Other Abnormal Conditions Please Specify:
__________________ __________________
Please Specify Please Specify

TREATMENT RECORD TREATMENT RECORD

TOOTH NATURE OF TOOTH NATURE OF

DATE TREATMENT REMARKS DATE TREATMENT REMARKS
NO. OPERATION NO. OPERATION

Period Condition: DENTAL PROSTESIS Period Condition: DENTAL PROSTESIS

Normal Denture Wearer: Y N Remarks: __________________ Normal Denture Wearer: Y N Remarks: __________________

Gingivitis Please Specify: Gingivitis Please Specify:

Periodontal Disease Need for Denture: Y N Remarks: __________________ Periodontal Disease Need for Denture: Y N Remarks: __________________

Other Abnormal Conditions Please Specify: Other Abnormal Conditions Please Specify:
__________________ __________________
Please Specify Please Specify