POLANGUI COMMUNITY COLLEGE

Alnay, Polangui, Albay

INDIVIDUAL DENTAL HEALTH FORM

Academic Year: ____________
Name: __________________________________________________ Age: __________ Gender: M F
(Last Name) (First Name) (Middle Name)
Date of Birth: _____/_____/_____ Civil Status: __________ Nationality: _____________ Religion: ___________
Course/Year Level:_______________________ Student’s Contact Number: ____________________________
Home Address: __________________________________________________________________________________
Name of Parent / Guardian: ___________________________________ Occupation: ____________________
Parent/Guardian Contact Number: _____________________________________________

PATIENT’S HISTORY: (To be filled by the patient / student) - PLEASE CHECK

1. Allergy to food / medication? ___ YES ___ NO

If with Allergy, specify (ex. To shrimp, penicillin, etc) _____________________________________
2. Blood Diseases? ___YES ___NO If Yes, what? ________________________________________
3. History of Fainting? ___ YES ___ NO If Yes, what causes: _________________________________
4. Heart Ailments? ___ YES ___ NO
5. With Hepatitis? ___ YES ___ NO
6. Suffering from frequent Headaches? ___ YES ___ NO
7. With hypertension? ___ YES ___ NO

Blood Pressure: ____________ mmHg

ORAL HEALTH CONDITION

Date of
Examination RIGHT LEFT
CARIES
GINGIVITIS
P. POCKETS
ORAL DEBRIS
CALCULAR UPPER
DEPOSIT TEETH
NEOPLASM
CLEFT-LIP
CLEFT PALATE
OTHERS

T P T P T P T P T P T P
NO. OF TEETH
NO. OF DMFT
NO. OF DF
TEETH

Note:
T – Temporary
P – Permanent
DMFT - Decayed, Missing, and Filled Permanent Teeth
DF – Demineralization
LOWER

Legend: TEETH

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To be completed by dentist:

Oral Health Status (check all that apply) Treatment Needs (check all that apply)
YES NO Dental Sealants Present
Urgent Treatment
YES NO Caries Experience / Restoration History Restorative Care
YES NO Untreated Caries Preventive Care
YES NO Soft Tissue Pathology Other
YES NO Malocclusion

TREATMENTS:

DATE TREATMENT TOOTH NO. NAME AND REMARKS

SIGNATURE OF DENTIST

The above findings are certified correct and are based on the dental examination, diagnostic results
available, and the disclosure of the student’s / parent’s pertinent dental history at the time and date
of examination.

Dentist’s Signature: _____________________________________

Dentist Name: (please print): _____________________________ Date of examination: _______________
License Number: _____________________________________ Phone #: _________________________
PTR Number: ____________________________________________ Fax #: _____________________________

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