Republic of the Philippines

Department of Education
HEALTH AND NUTRITION CENTER
PACUAN NATIONAL HIGH SCHOOL
ORAL HEALTH EXAMINATION RECORD FOR TEACHING
AND NON-TEACHING PERSONNEL

Name: VENUS L. DESIAR Age: 30 Gender: FEMALE

Date of Birth: AUGUST 30, 1991 Marital Status: SINGLE
Region: VII- CENTRAL VISAYAS Division: NEGROS ORIENTAL District: LA LIBERTAD II School: PACUAN NHS
Designation:
Medical History
Hypertension Epilepsy Allergies
Diabetes Bleeding Disorder Others:
Cardio Vascular Dis. Asthma
Please Specify
DENTITION STATUS INDEX: DMFT

Status
No. of T/Decayed X
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
Status

TREATMENT RECORD
DATE TOOTH NO. NATURE OF OPERATION REMARKS DENTIST

Periodontal Condition: DENTAL PROSTHESES

Y N
Normal Denture wearer: Remarks:

Gingivitis Please Specify:

Y N
Periodontal Disease Need for Denture: Remarks:
Other Abnormal Conditions Please Specify: Remarks:

Please Specify

SYMBOLS FOR MOUTH EXAMINATIONS Artificial Restoration: SYMBOLS FOR ACCOMPLISHMENT

X- carious tooth indicated F2- Permanently Filled tooth JC- Jacket Crow OP- Oral Prophylaxis ZnO F- Zinc Oxide Filling
for extraction with recurrence of decay AB- Abutment XI- Extracted R- Referred to private
F-Carious tooth indicated Heavy Shade-Permanent P-Pontic permanent tooth dentist
for filling Filling I- Inlay Ag F- Amalgam Filling
RF-Root fragment Outline of filling- tooth w/ RPD- Removable Partial Denture Sy F- Synthetic Porcelain
O- Missing tooth temporary filling FB- Fixed Bridge GIC- Glass Ionomer Cement
CD- Complete Denture
 TREATMENT RECORD
DATE TOOTH NO. NATURE OF OPERATION REMARKS DENTIST
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28

48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
No. of T/Decayed X
F
No. of T/Missing

No. of T/Filled

Total

DATE TOOTH NO.

NATURE OF OPERATION REMARKS DENTIST