Professional Documents
Culture Documents
Department of Education
Region VI – Western Visayas
SCHOOLS DIVISION OF ROXAS CITY
City of Roxas
Birthplace Division
Parent/Guardian Telephone No.
Address
Pre-Elem
Grade 7 Grade81
Grade Grade92
Grade Grade103
Grade Grade 4 Grade S Grade 6
Intervention
Intervention
Intervention
Intervention
Intervention
Intervention
Intervention
Finding
Finding
Finding
Finding
Finding
Finding
Finding
Date of Examination
Temperature/BP
Heart Rate/Pulse Rate/Respiratory Rate
Height
Weight
Nutritional Status (NS)
Visual Acuity (Snellen's)
a. N Rt, b. N Lf, c. AbN Rt, d. AbN Lf
Hearing (Tuning Fork)
a. N RI, b. N Lf, o. AbN Rt, d. AbN Lf
Skin/Scalp
Eyes/Ears/Nose
Mouth/Throat/Neck
Lungs/Heart
Abdomen/Genitalia
Spine/Extremities
Others, specify
Examined by
MEDICAL HISTORY
YES NO Guide Questions
Allergy
Asthma Do you have a toothbrush? Y N
Anemia How many times do you brush your teeth? Once 2x 3x
Bleeding Problem
Heart ailment How many times do you change your toothbrush in a year?
Diabetes
Epilepsy Do you use toothpaste in brushing? Y N
Kidney disease How many times do you visit the dentist in a year? once 2x
Convulsion
Fainting
ORAL HEALTH CONDITION
CONDITION AND TREATMENT NEEDS 7
Pre-SchooIer 18 92 10
3 4 5 6
CONDITION
RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT
Periodontal Disease
TEMPORARYTE ETH H U XOA
Malocclusion
Supermumentary
tooth
Retained deciducous
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
tooth
Decubital Ulcer
48 47 46 45 44. 43 42 41 31 32 33 34 35 36 37 38
Gleh lip/palate
CONDITION
TREATMENT Root fragment
NEEDS
Fluorosis
TEMPORARY TEETH
CONDITION