Republic of the Philippines

DEPARTMENT OF EDUCATION back to main

Region

Division

DENTAL HEALTH RECORD

Name:
Age: Sex Birth Date Date
Event:
Parent/Guardian:
Coach:
CONDITION AND TREATMENT NEEDS GINGIVITIS
CONDITION PERIODONTAL
RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT DISEASE
TEMPORARY TEETH MALOCCLUSION
SUPERNUMERARY
TOOTH
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 RETAINED
PERMANENT TEETH
DECIDOUS TEETH
DECUBITAL ULCER
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CALCULUS
CONDITION CLEFT PALATE
ROOT FRAGMENT
TREATMENT NEEDS
TEMPORARY TEETH FLUOROSIS
RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT OTHERS (Specify)
CONDITION

DATE OF VISIT
YEAR LEVEL REMARKS TEMPORARY TEETH
DATE INDEX D.F.T.
EXAMINATION NO. T /DECAYED
SEALANT (GI) NO. T/ FILLED
PERMANENT FILLING TOTAL D.F.T.
ART
EXTRACTION PERMANENT TEETH
ORAL PROPHYLAXIS INDEX D.F.T.
REFERRAL NO. T /DECAYED
OTHER ORAL TREATMENT NO. T/MISSING
NO. T/ FILLED
TOTAL D.F.T.
TOTAL SOUND TEETH
SYMBOLS FOR MOUTH EXAMINATION SYMBOLS FOR ACCOMPLISHMENT
X - TOOTH INDICATED DU - DECUBITAL ULCER XT - EXTRACTED PERMANENT TOOTH
FOR EXTRACTION MAL - MALOCLUSSION xt - EXTRACTED TEMPORARY TOOTH
F - TOOTH INDICATED FLU - FLUOROSIS Am - AMALGAM FILLING
FOR FILLING Gn - NORMAL Com - COMPOSITE FILLING
HEAVY - TOOTH WITH TEMPORARY Gm - MODERATE GINGIVITIS
SHADE FILLING (1-2 QUADRANTS) ARTIFICIAL RESTORATION
RC - RECURRENT CARIES Gs - SEVERE GINGIVITIS JC - JACKET CROWN
RF - ROOT FRAGMENT (3-4 QUADRANTS) I - INLAY
M - MISSING TOOTH CMR - COMPLETE MOUTH REHAB OP - ORAL PROPHYLAXIS
(√) - SOUND ERUPTED PERMANENT ZOE - ZINC OXIDE UEGENOL FILLING
TOOTH TF - TEMPORARY FILLING
R - REFERRED TO PRIVATE DENTIST
UN - UNERUPTED TOOTH
Division Meet Remarks/Findings:

DENTIST
(signature over printed name)
PRC: LICENSE: Date Examined:
Regional Meet Remarks/Findings:

DENTIST
(signature over printed name)
PRC: LICENSE: Date Examined:
Palarong Pambansa Remarks/Findings:

DENTIST
(signature over printed name)
PRC: LICENSE: Date Examined:
FOR PALARONG PAMBANSA ONLY
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 Republic of the Philippines
Department of Education
___________________________
(Region)
________________________
(Division)
____________________________________
(School)
_______________________________________________
( School Address )

MEDICAL CERTIFICATE

Date:

To Whom It May Concern:

This is to certify that I have personally examined

Name

age sex born on and have found that he/she is

physically fit, during the time of examination, to join and compete in the lower meets and
Palarong Pambansa.

Event:

Physical Examination

Date examined: _______________

Height Weight: Blood Pressure
Pulse, Resting Respiratory Rate
Other Remarks:

Physician/Medical Officer
(Signature over printed name)

License No.
PTR.:
Date:

FOR PALARONG PAMBANSA ONLY

back to main
 Republic of the Philippines
Department of Education
_______________________
(Region)
_____________________
(Division)
_____________________________________
(School)
__________________________________________
(School Address)

MEDICAL CERTIFICATE

QUESTION FOR ATHLETE: IF YES, EXPLAIN MEDICAL

PARENT
OFFICER
1. Is a doctor currently treating you for anything? YES NO YES NO

2. Have you ever been unconscious or had a concussion? YES NO YES NO

3. Have you been hit hard in the head in the last 6 weeks? YES NO YES NO

4. Have you had any headache in the last 2 weeks? YES NO YES NO

5. Do you have any problem in bleeding? YES NO YES NO

6. Does any disease run in your family ? Sudden unexpected death? YES NO YES NO

7. Have you had any surgery? YES NO YES NO

8. Have you ever had to stay in a hospital? YES NO YES NO

9. Do you have any medical condition? YES NO YES NO

______________________________
Name and signature (Parent)

______________________________
Physician/Medical Officer
(Signature over printed name)
License No.
PTR.:
Date:

FOR PALARONG PAMBANSA ONLY

back to main
 Republic of the Philippines
Department of Education
_____________________
(Region)
______________________
(Division)
_____________________________
(School)
_______________________________
(School Address)

MEDICAL CERTIFICATE ABNORMALITIES

Medical Examination following post period

If Athlete had a Concussion in the past year
after Concussion was normal Athlete Fit to Normal Abnormal
please certify that:
Box

List abnormalities not covered in specific

General Medical Exam
system exams below:

Mental Status/ Psychological Briet survey Normal Abnormal

Cranial nerves, eyes, pupil size and

Head Normal Abnormal
reactivity. Fundi, Vision by chart (record)

Mouth, teeth, throat, nose Normal Abnormal

Temporomandibular joint Normal Abnomal
Neck Cervical spine, lymph nodes Normal Abnomal

Chest Breath sounds, rib tenderness on compession Normal Abnormal

Pulse/ blood pressure (record) Normal Abnormal

Cardio Vascular System

Heart examination: sounds, murmurs,
Normal Abnormal
heaves, size, rhythm

Orthopedic System Upper limb: shoulder wrist, hand, fingers Normal Abnormal

Lower limb: (ankle, knee, hip Normal Abnormal

Relaxes Normal Abnormal

Neurological System Verbal responses Normal Abnormal
Motor responses and balance Normal Abnormal
Asthma (record) Yes No
Allergies Type of reaction (record)
Medications used Name and dosage (record) Yes No

Fit to Play Not Fit to Play

Name of Athlete:

Name of MD________________________________________
Lic. Number:______________________
Date:______________________

FOR PALARONG PAMBANSA ONLY

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