Republic of the Philippines

Department of the Interior and Local Govemment

BUREAU OF FIRE PROTECTION
REGIONAL OFFICE XII
Prime Regional Center, Brgy Carpenter Hill, City of Koronadal

BFP DENTAL HEALTH RECORD

SECTION I: PATIENT DATA
Rank Last Name First Name Middle Name Date of Birth

FT2
Unit Assignment
CAANAS Io/u/11
Home Address Telephone/Cllphone No
FP NH kiONPAWA CY COT AOAD 161246K(L
SECTION I: DENTAL EXAMINATION FOz Marvin Dae C Pore
PURPOSE OF EXAMINATION

INITIAL/ CONSULTATION D TRAINING PROMOTION

DATE: DATE/TYPE: DATE/TYPE:

MISSING TEETH AND EXISTING RESTORATIONS,DISEASES AND ABNORMALITIES

A. CALCULUs
MILD MODERATE D HEAVY

B. ABNORMALITIES/OCCLUSION / REMARKS

8 7 6 5 432 1 1 2 3 4 5 6 8
65 4 3 21 1 2 3 4 5 6
8

SECTION I:CASE HISTORY

Present Oral Complaint:

Medical History: Check the box

YES NONE YES NONE BP
Diabetes History of hypertension Systolic
Bleeding Tendency Asthma Diastolic

Drug Sensitivity Food allerBY

Examining Dentist:
SINSP MARLYCEL ROSE S LAMPREA, DMD

Signature of Personnel Date

Noted by:

SINSP MARLYCEL ROSE SLAMPREA,DMD

Chief, Dental Service BFP
REGIONXI

BFP-QSF-HS-001 A Rev, 0o (05.23.18) Front