Aepuoue OF URE FmUppInES ‘of Education HEALTH AND NUTRITION CENTER Pasi City ORAL HEALTH EXAMINATION RECORD FOR TEACHING AND NON-TEACHING PERSONNEL _ Age: — Marital Status __ ____ District: (1 Hypertension Cepitepey 1 Allergies {J Diabetes (C) Bleeding Disorder {TJ Others: (5) Cardio Vascular Dis. [} Asthma a DENTITION STATUS rea: INDEX : DMFT aH —— ov I] Te Ts [ Nor of Tiiesing Wo. of Vilted Total Periodontal Condition: DENTAL PROSTHESES (7 Normal Demure wearer: f=)” CN — 7 Gingiii Please Specify: Sascu 2 Periodontal Disease Need for Denture: LJ¥ CN ee Other Abnormal Conditions Please Specify: Remarks: Please Specify ‘SYMBOLS FOR MOUTH EXAMINATION SYMBOLS FOR ACCOMPLISHMENT X-carom wat mdeated — F2—Pemaneaty ied oth (OP Oral Propyleie ‘Za F- Le Oi ing ferme i recarence ot eeay KCextncted permanent R Read we pve do Carmi loth inset Herp Shae Permeaet ‘oot ‘er ng Fig AEF -Acatgan Fin, Stoo igen (ale fing tat So F Symtaae prea aiming ‘empoarySiing (GC gee mae cement {CD -Complee DeneTREATMENT RECORD DATE | TOOTH NO. NATURE OF OPERATION REMARKS DENTIST