ORAL HEALTH EXAMINATION RECORD FOR TEACHING AND NON-TEACHING PERSONNEL

Name: Age: Sex:

Date of Birth: Civil Status:
Region: IV-A Division: LAGUNA District: ALAMINOS School: BUENAVENTURA E. FANDIALAN MINHS

Designation: Employee Number

Telephone/Mobile No.:__ Email add
Facebook/ Messenger Link:
Medical History:

Hypertension Epilepsy Allergies

Diabetes Bleeding Disorder Others
Cardio Vascular Disease Asthma
Please Specify
DENTITION STATUS
INDEX : DMFT
X-
No. of T/Decayed
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 F-
No. of T/Missing
No. of T/Filled
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
Total

TREATMENT RECORD
DATE TOOTH NO. NATURE OF OPERATION REMARKS DENTIST

Periodontal Condition: DENTAL PROSTHESES

Normal
Denture wearer:
Remarks:
Gingivitis
Please Specify:
Periodontal Disease
Need for Denture:
Remarks:
Other Abnormal Conditions
Please Specify: Remarks:
Please Specify

SYMBOLS FOR MOUTH EXAMINATION Artificial Restoration: SYMBOLS FOR ACCOMPLISHMENT

Good Permanently filled tooth with Oral Zinc Oxide

✓ F2 -
recurrence of decay
JC - Jacket Crown OP -
Prophylaxis
ZnOF -
Filling

Carious tooth Extracted

X- Heavy Shade tooth with permanent Amalgam
indicated for AB - Abutment Xt - permanent AgF -
- filling Filling
extraction tooth
Synthetic
Carious tooth Outline of tooth with temporary Referred to
F- P- Pontic R- SyF - porcelain
indicated for filling filing - filling private
filling
dentist
Glass Ionomer
RF - Root Fragment I- Inlay GIC -
Filling
Removable Partial
M - Missing Tooth RPD - FB - Fixed Bridge CD - Complete Denture
Denture
DATE TOOTH NO. NATURE OF OPERATION REMARKS DENTIST