Republic of the Philippines

Department of Education
HEALTH AND NUTRITION CENTER
CITY OF NAGA

ORAL HEALTH EXAMINATION RECORD FOR TEACHING

AND
NON- TEACHING PERSONNEL
Name: _______________________________Age:
Date of Birth: __________________________Marital Status: _____________Gender: __________________
Region: ______________Division: District: _____________School: __________________
Designation: __________
Medical
History:
Hypertension Epilepsy Allergies
Diabetes Bleeding Other: _________________Please
Cardiovascular Disorder
Asthma Specify
Dis.
DENTITION STATUS INDEX: DMFT
Status
X-
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 No. of T/decayed
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

DATE TOOTH NO. NATURE OF OPERATION REMARKS DENTIST

TREATMENT RECORD

Normal Denture wearer:Please Specify:

Y N Remarks: ______________
Gingivitis _______________________
Remarks: ______________
Periodontal Need for Denture:PleaseYSpecify:N
Other _______________________
Abnormal Conditions: ________________
Disease Remarks: ______________
Please Specify
SYMBOLS FOR MOUTH EXAMINATION Artificial Restoration: SYMBOLS FOR
ACCOMPLISHMENT
X- Carious tooth indicated F2- Permanently filled tooth IC- Jacket Crown OP- Oral Prophylaxis
for extraction with recurrence of decay AB- Abutment X1- Extracted Percussion Tooth
Periodontal
F- Carious toothCondition:
indicated Heavy Shade- Permanent filling P- Pontic
DENTAL AGP- Amalgam Filling
for filling Outline of Filling- tooth with I- Inlay Sy P- Synthetic Porcelain
RF-Root Fragment temporary filling RPD- Removal Partial Denture GIC- Glass Ionomer
Cement
O- Missing tooth FB- Fixed Bridge ZoOF- Zinc Oxide Filling
CD- Complete Denture R- Referred to private dentist