ORAL HEALTH EXAMINATION RECORD FOR TEACHING

AND NON-TEACHING PERSONNEL

Name: ______________________________ Age:____ Gender: __________

Date of Birth: _________________ Marital Status: _____________
Region: CARAGA Division: DINAGAT ISLANDS District: SAN JOSE
School: Aurelio Elementary School Designation: ______________________
Medical History:
___Hypertension ___Epilepsy ___ Allergies
___Diabetes ___Bleeding Disorder Others Please Specify: _________________
___Cardio Vascular Dis. ___Asthma

DENTITION STATUS
No. of X-
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 T/Decayed
No. of F_
T/Missing
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
No. of
T/Missing
TOTAL
TREATMENT RECORD
DATE TOOTH NO. NATURE OF OPERATION REMARKS DENTIST

Periodontal Condition: DENTAL PROSTHESES Remarks: _________________

Normal Denture wearer: Y N
Gingivitis Please Specify: ____________
Periodontal Disease Need for Denture: Y N Remarks: ________________
Other Abnormal Conditions Please Specify: ____________ Remarks: ________________
______________________
Please Specify
SYMBOLS FOR MOUTH EXAMINATION Artificial Restoration: SYMBOLS FOR ACCOMPLISHMENT
X- Carious tooth indicated for extraction JC- Jacket Crown OP- Oral Prophylaxis
F2- Permanently filled tooth with recurrence of decay AB- Abutment Xt-Extracted permanent tooth
F-Carious tooth indicated for filling P-Pontic Ag F- Amalgam Filling
Heavy Shade- Permanent filling I- Inlay SY F- Synthetic porcelain
Outline of filling – tooth w/ temporary filling RPD-Removable Partial Denture GIC- Glass Ionomer Cement
O- Missing tooth FB-Fixed Bridge ZnO F- Zinc Oxide Filling
RF- Root Fragment CD- Complete Denture R- Referred to private dentist