Form No.

15-DS-008, Revised January 2019

UNIVERSITY HEALTH SERVICE *Do not use sign
University of the Philippines Los Baños pens. Print on half
College, Laguna A4 paper.
DENTAL EXAMINATION
Name:______________________________________________________ Date:___________________
(Last) (First) (Middle)
Age:____ Sex:____ Civil Status:_______ Parent/Guardian/Spouse: _____________________________
Home Address:______________________________________________ Tel. No.:_________________
Course:____________________________________________________ Tel. No.:_________________
LEGEND:
55 54 53 52 51 61 62 63 64 65
▪X-missing/ extracted
/unerupted
▪RF-root fragment
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
▪Am-amalgam
▪Co-composite
▪TF-temporary filing
▪PFS-pit & fissure
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 sealants
- filling (blue ink)
- - carious (red ink)
85 84 83 82 81 71 72 73 74 75 - crowns
- fixed bridge
ORAL HYGIENE: ▪GOOD ▪FAIR ▪POOR
OCCLUSION: ▪WNL ▪GROSS MALOCCLUSION:_____________________________________
PROSTHETICS: ▪NONE ▪U / L RPD ▪U / L CD
ORTHODONTICS: ▪U / L HAWLEY ▪BRACKETS ▪OTHERS: __________________________
REMARKS:___________________________________________________________________________

Dentist’s Signature Above Printed Name:_________________________________PRC Lic. No.________

Complete Clinic Address:________________________________________________________________
Contact No/s.:__________________________________Email Address/es:________________________

------------------------------------------------------------------------------
RECOMMENDATIONS FOR THE PATIENT (Patient’s Copy)

Patient’s Name:_________________________________________________________________
[ ] Extraction _____________________ [ ] Oral prophylaxis__________________________
[ ] Fillings _______________________ [ ] Topical fluoride application _________________
[ ] Root canal treatment_____________ [ ] Orthodontic treatment _____________________
[ ] Prosthetics ____________________ [ ] X-ray __________________________________
[ ] Surgery ______________________ [ ] Others_________________________________

___________________________________
Dentist’s signature over printed name
License no.:______________
Date: ___________________