Republic of the Philippines

BICOL UNIVERSITY
BICOL UNIVERSITY HEALTH SERVICES
Legazpi City INDIVIDUAL DENTAL HEALTH RECORD
CP # 09171878940

COURSE/YEAR: _________________________
SCHOOL YEAR: _________________________
CAMPUS: _____________________________

(Use BLUE permanent ink. DO NOT USE sign pen. Print on Legal size paper back-to back))

Name ______________________________________________________________________________ Age ______ Gender ________

(Last) (First) (Middle)
Date of Birth _________________ Civil Status: ________________ Nationality : __________________ Religion __________________
Home Address: ________________________________________________________________________________________________
Name of Parent/Guardian: _____________________________________________ Occupation: _______________________________
Parent/Guardian Contact Number: ____________________________ Student’s Contact Number: _____________________________

LEGEND:

√ - CARIES FREE SOUND TOOTH

C – CARIES
CI- DENTAL CARIES WITH
EXPOSED PULP.
AB- ABCESS
RF- ROOT FRAGMENT
CD- CALCULAR DEPOSIT
G – GINGIVITIS
TF- TEMPORARY FILLING
PF – PERMANENT FILLING
M – MISSING/UNERUPTED
AB- ABUTMENT
JC- JACKET CROWN
PG- PRESCRIPTION GIVEN
X – INDICATED FOR
EXTRACTION
XM- EXTRACTED
OA- NEED ORTHODONTIC
APPLIANCE
P- PONTIC

I – PATIENT’S HISTORY: (To be filled by the patient/student) – PLEASE CHECK

1. OPERATION (In any part of the body)? □ YES □ NO

If yes, specify (ex. Appendectomy) __________________________________________________________
2. Any allergy to food or medication? □ YES □ NO
If with allergy, specify (ex. To shrimp, penicillin, etc.) ____________________________________________
3. Blood Diseases? □ YES □ NO If yes, what? _____________________________
4. Fainted? □ YES □ NO If yes, what causes: _______________________
5. Do you have attacks of Asthma? □ YES □ NO With history? ____ Date of last attack ________
6. Do you have Heart Ailments? □ YES □ NO If yes? What? ____________________________
7. With Hepatitis? □ YES □ NO If yes? What? ____________________________
8. Pulmonary Tuberculosis □ YES □ NO Radiographic Interpretation: ________________
9. Suffering from Frequent Headaches? □ YES □ NO If yes, Why? _____________________________
10. With Hypertension? □ YES □ NO

II –BLOOD PRESSURE: _____________ mmHg

Doc. No. BU-F-UHS-21

Effectivity: February 8, 2020
Revision: 2 Page 1 of 2
 DATE OF EXAMINATION
y y y y
AGE AT LAST BIRTHDAY /o /o /o /o
PRESENCE OF DENTAL CARIES Y N Y N Y N Y N
PRESENCE OF GINGIVITIS Y N Y N Y N Y N
PRESENCE OF PERIODONTAL POCKET Y N Y N Y N Y N
PRESENCE OF ORAL DEBRIS Y N Y N Y N Y N
PRESENCE OF CALCULAR DEPOSIT Y N Y N Y N Y N
PRESENCE OF NEOPLASM Y N Y N Y N Y N
PRESENCE OF DENTO-FACIAL ANOMALY Y N Y N Y N Y N
T P T P T P T P
T D
NUMBER OF TEETH PRESENT E
O
O CARIES INDICATED FOR FILLING C
A
T CARIES INDICATED FOR EXTRACTIO Y
H E
ROOT FRAGMENT D

C MISSING DUE TO CARIES M

O
U
FILLED OR RESTORED F
N
T TOTAL OF THE DMF TEEETH
OCCLUSION TYPE
FLOURIDE APPLICATION
EXAMINER

III – TREATMENTS:

DATE TREATMENT TOOTH No. DENTIST REMARKS

FOR BICOL UNIVERSITY HEALTH SERVICE DENTIST’S VALIDATION ONLY

The above findings are certified correct and are based on the dental examination, diagnostic results available, and the
disclosure of the student’s/parent’s pertinent dental history at the time and date of examination.

_______________________________________________ __________________ ____ __________ ________________

Signature over Printed Name of University Dentist License Number PTR Number Date of Examination

Doc. No. BU-F-UHS-21

Effectivity: February 8, 2020
Revision: 2 Page 2 of 2