ORAL HEALTH EXAMINATION RECORD FOR TEACHING AND NON-

TEACHING PERSONNEL

Name: _________________________________________ Age: _______________ Gender: ____________________

Date of Birth: ______________________ Marital Status: __________________
Region: ________________ Division: ________________ District: ________________ School: ________________
Designation: _______________________
Medical History:
Hypertension Epilepsy Allergies
Diabetes Bleeding Disorder Others: ______________________
Cardio Vascular Dis. Asthma (Please Specify)

DENTITION STATUS INDEX: DMFT

TREATMENT RECORD
DATE TOOTH NO. NATURE OF OPERATION REMARKS DENTIST

Periodontal Condition: DENTAL PROSTHESES

Normal Dental wearer: Y N Remarks: __________________
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 ZnO F – Zinc Oxide Filling
F – carious tooth indicated for filling AB – Abutment X – Extracted Permanent R – referred to private dentist
RF – Root fragment P - Pontic Tooth
O – Missing tooth I – Inlay Ag F – Amalgam Filling
F2 – Permanently, filled tooth with recurrence RPD – Removable Partial Sy F – Synthetic Porcelain
of decay Denture
Heavy Shade – Permanent Filling FB – Fixed Bridge GIC – glass ionomer cement
Outline of Filling – tooth with temporary CD – Complete Denture
filling