ORAL EXAMINATION FORM

Name: __________________________ __________________________ _________

Surname First Name Middle Name
Date of Birth: ___________________ Age: _____ Sex: ________________
Course/Department/ ___________________________ Civil Status: ________________
Unit:

Address: ________________________________________ Contact Number: ______________

Name of Parent/ ______________
Guardian for minor: _____________________________ Contact Number: ______________

INTRAORAL EXAMINATION:

Legend:
/ - caries free Condition:
D - caries indicated for filling RF- Root fragment S - Sealant filled
X - caries indicated for M - Missing tooth St - Supernumerary
extraction AF- Amalgam filled tooth
LCF- Light cure composite filled
TF- Temporary filled
U - Unerupted

Periodontal Screening: Occlusion: Appliance: TMD:

☐ Gingivitis ☐ Class (Molar) ☐ Orthodontic ☐ Clenching
☐ Early Periodontitis ☐ Overjet ☐ Denture/s ☐ Clicking
☐ Moderate Periodontitis ☐ Overbite ☐ Others (Specify) ☐ Trismus
☐ Advance Periodontitis ☐ Midline Deviation ☐ Muscle Spasm

Remarks:

Date of Oral December 25, 2020

Examination:

________________________
DENTIST

DMMMSU-MDS-F003
Rev No. 01 (03.11.2022)
 ORAL EXAMINATION FORM

DMMMSU-MDS-F003
Rev No. 01 (03.11.2022)