Republic of the Philippines

DEPARTMENT OF EDUCATION
Region XI
DIVISION OF DAVAO DEL SUR

SCHOOL ORAL HEALTH EXAMINATION CARD

NAME OF PUPIL : GRADE/ SECTION:

Guide Questions
Do you have a toothbrush? Y N
How many times do you brush your teeth? Once Twice Thrice
How many times do you change your toothbrush in a year?
Do you use toothpaste in brushing?
How many times do you visit the dentist in a year?

6 6

5 5

4 4

3 3

2 2

1 1

Kinder Kinder

55 54 53 52 51 61 62 63 64 65
TEMPORARY TEETH

6/12 6/12

5/11 5/11

4/10 4/10

RIGHT 3/9 3/9 LEFT

2/8 2/8

I/7 I/7

Kinder Kinder

18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28

Grade/
Grade/ PERMANENT TEETH
School Year Year Level
Year
Level

48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 Examined by:
Kinder Kinder

I/7 I/7

2/ 8 2/ 8

3/9 3/9

4/10 4/10

5/11 5/11

6/12 6/12

TEMPORARY TEETH
85 84 83 82 81 71 72 73 74 75
Kinder Kinder

1 1
2 2
RIGHT 3 3 LEFT

4 4
5 5
6 6

1 2 3 4 5 6 1 2 3 4 5 6
TEMPORARY TEETH Kinder PERMANENT TEETH Kinder
7 8 9 10 11 12 7 8 9 10 11 12
Index d.f.t. Index D.M.F.T.
No. t / decayed No. T / decayed
No. t / filled No. T / Missing
Total d.f.t. No. T. / Filled
For Extraction Total D.M.F.T.
For Filling For Extraction
Total Sound teeth For Filling
Total Sound teeth

SYMBOL FOR MOUTH EXAMINATION

X - Carious tooth indicated for extraction (ü) - Sound/erupted Permanent/Temporary tooth FB - Fixed Bridge
D - Carious tooth indicated for filling PFS - Pit and Fissure Sealant CD - Complete Denture
RF - Root fragment JC - Jacket Crown GI - Glass Ionomer
O - Missing tooth P - Pontic SyF - Composite
F2 - Permanently filled tooth with RPD - Removable Partial Denture AgF - Amalgam
recurrence of decay
NAME OF PUPIL : GRADE/ SECTION:

Medical History Yes No Remarks

Allergy
Asthma
Anemia
Bleeding problem
Heart Ailment
Diabetes
Epilepsy
Kidney Disease
Convulsion
Fainting

ORAL HEALTH Kinder 1 2 3 4 5 6

CONDITION 7 8 9 10 11 12
Gingivitis
Periodontal Disease
Malocclussion
Supernumerary teeth
Retained decidous teeth
Decubital ulcer
Calculus
Cleft lip / palate
Root fragment
Fluorosis
Others, Specify

INTERVENTION/TREATMENT RECORD

Intervention/ Treatment Attended by:

Date Chief Complaint
Done
Remarks (Name & Position)