Revised as of September 26, 2019

DEPARTMENT OF EDUCATION
2
Region
ISABELA
Division

DENTAL HEALTH RECORD

Name:
Age: Sex: Birth Date:

Event:
nt/Guardian:

CONDITION AND TREATMENT Latest 1½ x 1½ picture

NEEDS
CONDITION
RIGHT LEFT
TEMPORARY TEETH

PERMANENT
TEETH

CONDITION

TREATMENT NEEDS
TEMPORARY TEETH
RIGHT LEFT

CONDITIO
N

YEAR LEVEL REMARKS

DATE
EXAMINATION
SEALANT (GI)
PERMANENT FILLING
ART
EXTRACTION
ORAL PROPHYLAXIS
REFERRAL
OTHER ORAL
TREATMENT

SYMBOLS FOR MOUTH EXAMINATION SYMBOLS FOR ACCOMPLISHMENT

X - TOOTH INDICATED DU -DECUBITAL ULCER XT - EXTRACTED PERMANENT TOOTH
HE FOR EXTRACTION MAL -MALOCLUSSION xt - EXTRACTED TEMPORARY TOOTH
AV
YF - TOOTH INDICATED FLU -FLUOROSIS Am - AMALGAM FILLING
SH FOR FILLING Gn -NORMAL Com - COMPOSITE FILLING
AD - TOOTH WITH TEMPORARY Gm -MODERATE GINGIVITIS
E FILLING (1-2 QUADRANTS) ARTIFICIAL RESTORATION
RC - RECURRENT CARIES Gs - SEVERE GINGIVITIS JC - JACKET CROWN
RF - ROOT FRAGMENT (3-4 QUADRANTS) I - INLAY
M - MISSING TOOTH CMR - COMPLETE MOUTH REHAB OP - ORAL PROPHYLAXIS
(√) - SOUND ERUPTED PERMANENT ZOE - ZINC OXIDE UEGENOL FILLING
 TOOTH TF - TEMPORARY FILLING
R - REFERRED TO PRIVATE DENTIST
UN - UNERUPTED TOOTH

Legislative District Meet Remarks/Findings:

WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTICiPATE:
PRC: LICENSE: PTR# Date Examined: YES NO
Division Meet Remarks/Findings:
WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTICIPATE:
PRC: LICENSE: PTR# Date Examined: YES NO
Regional Meet Remarks/Findings:
WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
nt/Guardian:

WITH THIRD MOLAR: REFERRE

DENTIST YES NO YES NO
(signature over printed name) QUALIFIED TO PARTICIPATE:
PRC: LICENSE: PTR# Date Examined: YES NO

FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)