Republic of the Philippines

BICOL UNIVERSITY
BICOL UNIVERSITY HEALTH SERVICES
Legazpi City INDIVIDUAL DENTAL HEALTH RECORD
CP # 09171878940

COURSE/YEAR: _________________________
SCHOOL YEAR: _________________________
CAMPUS: _____________________________

(Use BLUE permanent ink. DO NOT USE sign pen. Print on Legal size paper back-to back))

Name ______________________________________________________________________________ Age ______ Gender ________

(Last) (First) (Middle)
Date of Birth _________________ Civil Status: ________________ Nationality : __________________ Religion __________________
Home Address: ________________________________________________________________________________________________
Name of Parent/Guardian: _____________________________________________ Occupation: _______________________________
Parent/Guardian Contact Number: ____________________________ Student’s Contact Number: _____________________________

LEGEND:

√ - CARIES FREE SOUND TOOTH

C – CARIES
CI- DENTAL CARIES WITH
EXPOSED PULP.
AB- ABCESS
RF- ROOT FRAGMENT
CD- CALCULAR DEPOSIT
G – GINGIVITIS
TF- TEMPORARY FILLING
PF – PERMANENT FILLING
M – MISSING/UNERUPTED
AB- ABUTMENT
JC- JACKET CROWN
PG- PRESCRIPTION GIVEN
X – INDICATED FOR
EXTRACTION
XM- EXTRACTED
OA- NEED ORTHODONTIC
APPLIANCE
P- PONTIC

I – PATIENT’S HISTORY: (To be filled by the patient/student) – PLEASE CHECK

1. OPERATION (In any part of the body)? □ YES □ NO

If yes, specify (ex. Appendectomy) __________________________________________________________
2. Any allergy to food or medication? □ YES □ NO
If with allergy, specify (ex. To shrimp, penicillin, etc.) ____________________________________________
3. Blood Diseases? □ YES □ NO If yes, what? _____________________________
4. Fainted? □ YES □ NO If yes, what causes: _______________________
5. Do you have attacks of Asthma? □ YES □ NO With history? ____ Date of last attack ________
6. Do you have Heart Ailments? □ YES □ NO If yes? What? ____________________________
7. With Hepatitis? □ YES □ NO If yes? What? ____________________________
8. Pulmonary Tuberculosis □ YES □ NO Radiographic Interpretation: ________________
9. Suffering from Frequent Headaches? □ YES □ NO If yes, Why? _____________________________
10. With Hypertension? □ YES □ NO

II –BLOOD PRESSURE: _____________ mmHg

Doc. No. BU-F-UHS-21

Effectivity: February 8, 2020
Revision: 2 Page 1 of 2