ELEM - Examination Form

Document Code: SDOPAMP-QF-
Republic of the Philippines SGOD-SHS-020

Department of Education
Region III Revision: 00
Schools Division Office of Pampanga Effectivity date: 05-08-2018
DOCUMENT TITLE:
Name of Office:
SCHOOL DENTAL EXAMINATION CARD
School Health Section
(ELEMENTARY)
NAME: _________________________________ School:_____________________

LRN: ___________________________________ School ID: __________________
Date of Birth: __________________
Birth Place: ____________________
Parent/Guardian: ____________________ District: _____________________
KINDER
KINDER S.Y. GRADE
1 1 S.Y. S.Y. No. _______________
Address: S.Y.
__________________________ GRADE Telephone
KINDER S.Y.
S.Y. GRADE
GRADE 1 1 S.Y.S.Y.
55 53
55 54 54 52
53 51
52 61
51 62
61 63
62 64
63 65
64 65 55 53
55 54 54 52
53 51
52 61
51 62
61 63
62 64
63 65
64 65
RIGHT 55 54
55 54 53
53 52
52 51
51 61
61 6262 6363 6464 6565 LEFT RIGHT 55 5554 5453 53
52 52
51 51
61 61
62 62
63 63
64 64
65 65 LEFT
TEMPORARY TEETH TEMPORARY TEETH
18 16
18 17 17 15
16 14
15 13
14 12
13 11
12 21
11 22
21 23
22 24
23 25
24 26
25 27
26 28
27 28 18 16
18 17 17 15
16 14
15 13
14 12
13 11
12 21
11 22
21 23
22 24
23 25
24 26
25 27
26 28
27 28
18 17
18 17 16
16 15
15 14
14 13
13 12
12 11
11 21
21 2222 2323 2424 2525 2626 27272828 18 1817 1716 1615 1514 1413 13
12 12
11 11
21 21
22 22
23 23
24 24
25 25
26 26 27 28
27 28
PERMANENT TEETH
PERMANENT TEETH
48 46
48 47 47 45
46 44
45 43
44 42
43 41
42 31
41 32
31 33
32 34
33 35
34 36
35 37
36 38
37 38 48 46
48 47 47 45
46 44
45 43
44 42
43 41
42 31
41 32
31 33
32 34
33 35
34 36
35 37
36 38
37 38
48 47
48 47 46
46 45
45 44
44 43
43 42
42 41
41 31
31 3232 3333 3434 3535 3636 37373838 48 4847 4746 4645 4544 4443 43
42 42
41 41
31 31
32 32
33 33
34 34
35 35
36 36 37 38
37 38
TEMPORARY TEETH
TEMPORARY TEETH
85 85 83
84 83 81
82 81 72
71 72 73 74 75 85 83
84 82
83 81
82 71
81 72
71 73
72 74
73 75
74 75
RIGHT 85 84
84 83 82
82 81 71
71 72 7373 7474 7575
85 84 83 82 81 71 72 73 74 75 LEFT RIGHT 85 8584
85 84 8483 83
82 82
81 81
71 71
72 72
73 73
74 74
75 75 LEFT
GRADE
GRADE
GRADE
GRADE 222 2 S.Y. S.Y.
S.Y.
S.Y. GRADE
GRADE
GRADE 33 3 3
GRADE S.Y.
S.Y.S.Y.
S.Y.
55 54 53 52 51 61 62 63 64 65 55 54 53 52 51 61 62 63 64 65
RIGHT 55
55 54
55 53
54 54 52
53 53 51
52 52 61
51 51 62
61 61 63
62 62 64
63 63 65
64 64 65 LEFT
65 RIGHT55
55 54
55 53
54 54 52
53 53 51
52 52 61
51 51 62
61 61 63
62 62 64
63 63 65
64 64 65
65 LEFT
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
18 16
18 17 17 15
16 14
15 13
14 12
13 11
12 21
11 22
21 23
22 24
23 25
24 26
25 27
26 28
27 28 18 16
18 17 17 15
16 14
15 13
14 12
13 11
12 21
11 22
21 23
22 24
23 25
24 26
25 27
26 28
27 28
PERMANENT TEETH
PERMANENT TEETH
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
48 46
48 47 47 45
46 44
45 43
44 42
43 41
42 31
41 32
31 33
32 34
33 35
34 36
35 37
36 38
37 38 48 46
48 47 47 45
46 44
45 43
44 42
43 41
42 31
41 32
31 33
32 34
33 35
34 36
35 37
36 38
37 38
85 84 83 82 81 71 72 73 74 75 85 84 83 82 81 71 72 73 74 75
85 84 83 82 81 71 72 73 74 75 85 84 83 82 81 71 72 73 74 75
RIGHT 85 83
85 84 84 82
83 81
82 71
81 72
71 73
72 74
73 75
74 75 LEFT RIGHT 85 84
85 83
84 82
83 81
82 71
81 72
71 73
72 74
73 75
74 75 LEFT
QM-Page 1 of 1
One DepEd… One Pampanga

DOCUMENT TITLE:
Name of Office:
(ELEMENTARY)
NAME: _________________________________ School:_____________________

LRN: ___________________________________ School ID: __________________
Date of Birth: __________________
Birth Place: ____________________
Parent/Guardian: ____________________ District: _____________________
Address: __________________________ Telephone No. _______________
GRADE
GRADE44 S.Y.
S.Y. GRADE
GRADE5 5 S.Y.S.Y.
RIGHT 55
55 54
54 53
53 52
52 51
51 6161 6262 6363 6464 6565 LEFT RIGHT 55 5554 5453 5352 5251 5161 6162 6263 6364 6465 65 LEFT
18
18 17
17 16
16 15
15 14
14 13
13 12
12 11
11 2121 2222 2323 2424 2525 2626 2727 2828 18181717161615 1514 1413 1312 1211 1121 2122 2223 2324 2425 25
26 26
27 27
28 28
PERMANENT TEETH
PERMANENT TEETH
48
48 47
47 46
46 45
45 44
44 43
43 42
42 41
41 3131 3232 3333 3434 3535 3636 3737 3838 48484747464645 4544 4443 4342 4241 4131 3132 3233 3334 3435 35
36 36
37 37
38 38
RIGHT 85
85 84
84 83
83 82
82 81
81 7171 7272 7373 7474 7575 LEFT RIGHT 85 8584 8483 8382 8281 8171 7172 7273 7374 7475 75 LEFT
GRADE 6 S.Y.
RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT
TEMPORARY TEETH
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
PERMANENT TEETH
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
TEMPORARY TEETH
RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT
QM-Page 1 of 1

DOCUMENT TITLE:
Name of Office:
(ELEMENTARY)
TEMPORARY TEETH dft index PERMANENT TEETH

1 2 3 4 5 6
Index d.f.t. Kinder 1 2 3 4 5 6 Index D.M.F.T. Kinder 7 8 9 10 11 12
No. T / decayed No. T / decayed
No. T / filled No. T / Missing
Total d.f.t. No. T. / Filled
For Extraction Total D.M.F.T.
For Filling For Extraction
Total Sound teeth For Filling
Total Sound teeth
SYMBOL FOR MOUTH EXAMINATION

X - Carious tooth indicated for extraction () - Sound/erupted Permanent tooth FB - Fixed Bridge
D - Carious tooth indicated for filling PFS - Pit and Fissure Sealant CD - Complete Denture
RF - Root fragment JC - Jacket Crown GI - Glass Ionomer
M - Missing tooth PFS - Pontic CO - Composite
F2 - Permanently filled tooth with RPD - Removable Partial Denture AM - Amalgan
recurrence of decay
INTERVENTION/TREATMENT RECORD
Date Chief Complaint Intervention/Treatment Done Remarks Attended by (Name/Position)
QM-Page 1 of 1


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ELEM - Examination Form

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Document Code: SDOPAMP-QF-

Republic of the Philippines SGOD-SHS-020

NAME: _____________ School:_

One DepEd… One Pampanga

NAME: _____________ School:_

TEMPORARY TEETH TEMPORARY TEETH

One DepEd… One Pampanga

TEMPORARY TEETH dft index PERMANENT TEETH

SYMBOL FOR MOUTH EXAMINATION

Date Chief Complaint Intervention/Treatment Done Remarks Attended by (Name/Position)

One DepEd… One Pampanga

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