Republic of the Philippines

Department of Education
CARAGA REGION
DIVISION OF BUTUAN CITY

ORAL HEALTH EXAMINATION RECORD FOR TEACHING

AND NON-TEACHING PERSONNEL

Name: _____________________________________________ Age: _____ Gender: ________

Date of Birth: _________________ Marital Status: ______________
Region: _______ Division __________ District: ____________________
School: _________________________________________ Designation: ________________
DENTITION STATUS
No. of X-
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 T/Decayed
No. of F_
T/Missing
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 No. of
T/Missing
TOTAL
TREATMENT RECORD
DATE TOOTH NATURE OF OPERATION REMARKS DENTIST
NO.

Periodontal Condition: DENTAL PROSTHESES Remarks: _________________

Normal Denture wearer: Y N
Gingivitis Please Specify: ____________
Periodontal Disease Need for Denture: Y N Remarks: ________________
Other Abnormal Conditions Please Specify: ____________ Remarks: ________________
______________________
Please Specify

SYMBOLS FOR MOUTH EXAMINATION Artificial Restoration: SYMBOLS FOR ACCOMPLISHMENT

X- Carious tooth indicated for extraction JC- Jacket Crown OP- Oral Prophylaxis
F2- Permanently filled tooth with recurrence of decay AB- Abutment Xt-Extracted permanent tooth
F-Carious tooth indicated for filling P-Pontic Ag F- Amalgam Filling
Heavy Shade- Permanent filling I- Inlay SY F- Synthetic porcelain
Outline of filling – tooth w/ temporary filling RPD-Removable Partial Denture GIC- Glass Ionomer Cement
O- Missing tooth FB- Fixed Bridge ZnO F- Zinc Oxide Filling
CD- Complete Denture R- Referred to private dentist

Rosal Street, Brgy. Dagohoy, Butuan City 8600 (085) 3410022 / (085) 817 986 butuan.city@deped.gov.ph