CENTRO ESCOLAR UNIVERSITY

Makati

DENTAL RISK ASSESSMENT FORM

Student Number: 2021-20946 College/Department: College of Science & Technology/ Psychology Department Course/Year
& Section: BSPSY1AS-23

Name: Tacad Samantha Nicole C.

(Surname) (First Name) (Middle Initial)

Date of Birth: May 14, 2003 Age: 18 Sex: Female Nationality: Filipino Civil Status: Single

Religion: Roman Catholic Telephone/Cellphone Number: 09171030212

Home Address: 129 Narra Street Comembo, Makati City

Email Address: tacad2120946@mkt.ceu.edu.ph

MEDICAL AND DENTAL HISTORY: (-) Absence, (+) Presence; please specify:

Allergies: Allergic Rhinitis, Nuts and Peanuts Diabetes: (-) Blood Dyscrasia: (-)

CNS Disorder: (-) Cardiovascular Disease: (-) Others: _____________

Major Dental Surgical Procedure/s done: (Include the date) ________________________________

To be accomplished by the University Dentist:

Evaluated By: _______________________________

Date: ____________________

Remarks/Recommendations:
_____________________________________________________________________________________
_____________________________________________________________________________________
 Please answer in each number which describes your Dental Health Condition

1. How is your dental health at present? 10. Do you use Dental Floss
  Good   Yes
  Fair   No
  Poor 11. Do you use Mouthwash
2. When did you have your last dental visit?   Yes
July 2020    No
3. Reason for the dental visit? 12. Do you have dentures/dental prosthesis?
  Tooth pain     Yes
  Regular check- up     Upper only
  Oral prophylaxis   Lower only
  Swollen gums   Complete denture
  Any reason, specify   Upper removable partial denture
 Teeth Cleaning         Lower removable partial denture
          Fixed prosthesis
4. Do you have any cavities/ tooth decay?   Other, pls. specify
  Yes      
  No        
5. Do you complain of mouth pain?     No
  Yes 13. How often do you clean your dentures?        
  No 14. How do you clean them? 
If yes, what part of the mouth?   Water + toothbrush
            Water + dentrifice + toothbrush
6. Do your gums bleed?   Soak in water
  Yes 15. Are you under orthodontic treatment?   Yes   No
  No Since when did you have your braces?          
If yes, when?       16. When was your last adjustment done?          
7. How often do you brush your teeth? 17. Urgent dental need for the last 14 days
  2x a day If yes, tick all that applies
  3x a day   Uncontrolled dental / oral pain
  Every after meal   Swelling
  Before going to bed   Infection
8. Do you brush/clean     Trauma
  Roof of the mouth (palate)   None
  Tongue
  Gum (ridge)
9. Do you use a toothpaste with Fluoride in it?
  Yes
No

I certify that all responses made on this DENTAL RISK ASSESSMENT QUESTIONNAIRES are true and
accurate, that the information provided will be treated confidentially and is protected under the Data Privacy Act
of 2012. I understand that this form is for information purposes only and in no way obligates the University to
take any responsibility for my dental health and must be destroyed appropriately after a year otherwise specified.
   

CONFORME: Name and Signature of Student/ Employee Samantha Nicole C. Tacad