R epublic of the P hilippines

D epartment of Education
Region II – Cagayan Valley
SCHOOLS DIVISION OF QUIRINO

DENTAL HEALTH CARD

Name: ___________________________________________ Date of Birth : _________________ Age: ________ Sex: M F
School/ District/ Division : __________________________________________ Grade Level: ________

ORAL HEALTH CONDITION DMFT INDEX

Gingival condition: No. T / Decayed
RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT Normal No. T / Missing
TEMPORARY TEETH Gingivitis No. T. / Filled
Periodontitis Total D.M.F.T.
Denture wearer: For Extraction
PERMANENT TEETH

18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 Fixed Partial Denture For Filling

Removable Partial Denture Total Sound teeth
Complete Denture
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 In need of Denture:
Fixed Partial Denture
Removable Partial Denture
TEMPORARY TEETH Complete Denture
RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT Other oral conditions:
Malocclusion
with lesion
(red/blue/black/white)

SYMBOL FOR MOUTH EXAMINATION

X - Carious tooth indicated for extraction (ü) - Sound/erupted Permanent/Temporary tooPFS - Pit and Fissure Sealant
D - Carious tooth indicated for filling FPD - Fixed Partial Denture GI - Glass Ionomer
RF - Root fragment JC - Jacket Crown Co - Composite
M - Missing tooth RPD - Removable Partial Denture AM - Amalgan
Un - Unerupted CD - Complete Denture F2 - Permanently filled tooth
with recurrence of decay

INTERVENTION / TREATMENT
DATE Chief Complaint Intervention / Treatment Attended By

S-SHN-022-0
 R epublic of the P hilippines
D epartment of Education
Region II – Cagayan Valley
SCHOOLS DIVISION OF QUIRINO

INTERVENTION / TREATMENT
DATE Chief Complaint Intervention / Treatment Attended By

S-SHN-022-0
 R epublic of the P hilippines
D epartment of Education
Region II – Cagayan Valley
SCHOOLS DIVISION OF QUIRINO

DENTAL HEALTH CARD

Name: ___________________________________________ Date of Birth : _________________ Age: ________ Sex: M F
School/ District/ Division : __________________________________________ Civil Status: M S W S

ORAL HEALTH CONDITION DMFT INDEX

Gingival condition: No. T / Decayed
RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT Normal No. T / Missing
TEMPORARY TEETH Gingivitis No. T. / Filled
Periodontitis Total D.M.F.T.
Denture wearer: For Extraction
PERMANENT TEETH

18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 Fixed Partial Denture For Filling

Removable Partial Denture Total Sound teeth
Complete Denture
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 In need of Denture:
Fixed Partial Denture
Removable Partial Denture
TEMPORARY TEETH Complete Denture
RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT Other oral conditions:
Malocclusion
with lesion
(red/blue/black/white)

SYMBOL FOR MOUTH EXAMINATION

X - Carious tooth indicated for extraction (ü) - Sound/erupted Permanent/Temporary tooPFS - Pit and Fissure Sealant
D - Carious tooth indicated for filling FPD - Fixed Partial Denture GI - Glass Ionomer
RF - Root fragment JC - Jacket Crown Co - Composite
M - Missing tooth RPD - Removable Partial Denture AM - Amalgan
Un - Unerupted CD - Complete Denture F2 - Permanently filled tooth
with recurrence of decay

INTERVENTION / TREATMENT
DATE Chief Complaint Intervention / Treatment Attended By

S-SHN-022-0