Republic of the Philippines

Department of Education
HEALTH AND NUTRITION CENTER
Pasig City

ORAL HEALTH EXAMINATION RECORD FOR TEACHING

AND NON-TEACHING PERSONNEL

Name: _____________________ Age: ___ Gender: __________

Date of Birth: _______________ Marital Status: _______
Region: IV-B MIMAROPA Division: Palawan District: _____________ School: ____________________
Designation: ____________

Medical History:

Hypertension Epilepsy Allergies

Diabetes Bleeding Disorder Others:

Cardiovascular Disease Asthma _______________________

Please Specify
DEN TI TION S TA TU S INDEX: DMFT

STATUS No. of X
T/Decayed
17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
F
18 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

TRE A TMEN T RECOR D

DATE TOOTH NO. NATURE OF OPERATION REMARKS DENTIST

Periodontal Condition: DENTAL PROSTHESES

Normal Denture 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 XAMINATION Artificial Restoration: SYMBOLS FOR ACCOMPLISHMENT

X – Carious tooth indicated for extraction F2 – Permanently filled tooth
F – Carious tooth indicated for filling with recurrence of decay
RF – Root Fragment Heavy S hade – Permanent filling
O – Missing tooth Outline of filling – tooth w/
temporary filling
JC – Jacket Crown OP – Oral Prophylaxis ZnO F - Zinc Oxide filling
AB – Abutment X – Extracted permanent R –Referred to private dentist
P – Pontic tooth
I – Inlay Ag F – Amalgam Filling
RPD – Removable Partial Denture S y F – S ynthetic porcelain
FB – Fixed Bridge GIC – Glass Ionomer Cement
CD – Complete Denture
 TRE A TMEN T RECORD
DATE TOOTH NO. NATURE OF OPERATION REMARKS DENTIST