Professional Documents
Culture Documents
DEPARTMENT OF EDUCATION
1
Region
SCHOOLS DIVISION OF ILOCOS SUR
Division
Name:
Age: Sex: Birth Date:
Event:
Parent/Guardian:
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
PERMANENT
TEETH
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
CONDITIO
N
TREATMENT NEEDS
TEMPORARY TEETH
RIGHT
85 84 83 82 81 71 72 73 74 75 LEFT
CONDITION
R
SCHOOLS DIV
Di
DENTAL HEA
Name:
Age: Sex:
Event:
Parent/Guardian:
55 54 53 52 51 61
18 17 16 15 14 13 12 11 21
48 47 46 45 44 43 42 41 31
85 84 83 82 81 71
YEAR LEVEL
DATE
EXAMINATION
SEALANT (GI)
PERMANENT FILLING
ART
EXTRACTION
ORAL PROPHYLAXIS
REFERRAL
OTHER ORAL
TREATMENT
District Meet
DENTIST
(signature over printed name)
PRC: LICENSE: PTR# Date Examined:
Division Meet
DENTIST
(signature over printed name)
PRC: LICENSE: PTR# Date Examined:
Regional Meet
DENTIST
(signature over printed name)
PRC: LICENSE: PTR# Date Examined:
Palarong Pambansa
DENTIST
(signature over printed name)
PRC: LICENSE: PTR# Date Examined:
Birth Date:
62 63 64 65
22 23 24 25 26 27 28
32 33 34 35 36 37 38
72 73 74 75
REMARKS
SYMBOLS FOR ACCOMPLISHMENT
DECUBITAL ULCER XT - EXTRACTED PERMANENT TOOTH
MALOCLUSSION xt - EXTRACTED TEMPORARY TOOTH
FLUOROSIS Am - AMALGAM FILLING
Com - COMPOSITE FILLING
MODERATE GINGIVITIS
(1-2 QUADRANTS) ARTIFICIAL RESTORATION
SEVERE GINGIVITIS JC - JACKET CROWN
(3-4 QUADRANTS) I - INLAY
COMPLETE MOUTH REHAB OP - ORAL PROPHYLAXIS
SOUND ERUPTED PERMANENT ZOE - ZINC OXIDE UEGENOL FILLING
TF - TEMPORARY FILLING
R - REFERRED TO PRIVATE DENTIST
UN - UNERUPTED TOOTH
Remarks/Findings:
WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
YES NO YES
QUALIFIED TO PARTICiPATE:
YES NO
Remarks/Findings:
WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
YES NO YES
QUALIFIED TO PARTICIPATE:
YES NO
Remarks/Findings:
WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
YES NO YES
QUALIFIED TO PARTCIPATE:
YES NO
Remarks/Findings:
WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
YES NO YES
QUALIFIED TO PARTICIPATE:
YES NO
ACCOMPLISHMENT
RESTORATION
ENT:
NO
ENT:
NO
ENT:
NO
ENT:
NO
Republic of
DEPARTMENT
R
SCHOOLS DIV
Di
DENTAL HEA
Name:
Age: Sex:
Event:
Parent/Guardian:
55 54 53 52 51 61
18 17 16 15 14 13 12 11 21
48 47 46 45 44 43 42 41 31
85 84 83 82 81 71
YEAR LEVEL
DATE
EXAMINATION
SEALANT (GI)
PERMANENT FILLING
ART
EXTRACTION
ORAL PROPHYLAXIS
REFERRAL
OTHER ORAL
TREATMENT
District Meet
DENTIST
(signature over printed name)
PRC: LICENSE: PTR# Date Examined:
Division Meet
DENTIST
(signature over printed name)
PRC: LICENSE: PTR# Date Examined:
Regional Meet
DENTIST
(signature over printed name)
PRC: LICENSE: PTR# Date Examined:
Palarong Pambansa
DENTIST
(signature over printed name)
PRC: LICENSE: PTR# Date Examined:
Birth Date:
62 63 64 65
22 23 24 25 26 27 28
32 33 34 35 36 37 38
72 73 74 75
REMARKS
SYMBOLS FOR ACCOMPLISHMENT
DECUBITAL ULCER XT - EXTRACTED PERMANENT TOOTH
MALOCLUSSION xt - EXTRACTED TEMPORARY TOOTH
FLUOROSIS Am - AMALGAM FILLING
Com - COMPOSITE FILLING
MODERATE GINGIVITIS
(1-2 QUADRANTS) ARTIFICIAL RESTORATION
SEVERE GINGIVITIS JC - JACKET CROWN
(3-4 QUADRANTS) I - INLAY
COMPLETE MOUTH REHAB OP - ORAL PROPHYLAXIS
SOUND ERUPTED PERMANENT ZOE - ZINC OXIDE UEGENOL FILLING
TF - TEMPORARY FILLING
R - REFERRED TO PRIVATE DENTIST
UN - UNERUPTED TOOTH
Remarks/Findings:
WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
YES NO YES
QUALIFIED TO PARTICiPATE:
YES NO
Remarks/Findings:
WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
YES NO YES
QUALIFIED TO PARTICIPATE:
YES NO
Remarks/Findings:
WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
YES NO YES
QUALIFIED TO PARTCIPATE:
YES NO
Remarks/Findings:
WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT:
YES NO YES
QUALIFIED TO PARTICIPATE:
YES NO
ACCOMPLISHMENT
RESTORATION
ENT:
NO
ENT:
NO
ENT:
NO
ENT:
NO