SHD Form 1

Republic of the Philippines

DEPARTMENT OF EDUCATION
Region ______________
Division of _____________________
______________________________________________
School Name/ID

SCHOOL HEALTH EXAMINATION CARD

Name:
Last First Middle
Date of Birth: Birthplace:

Month / Day / Year

School ID: Region:

Learner Reference Number (LRN): Division:

Parent/Guardian: Telephone No.:

Home Address:

Data Privacy Notice

The Department of Education shall engage in the collection of health / medical information for
the purposes of tracking, provision of necessary health / medical interventions, and educational
purposes. This information shall be processed in accordance with the provisions of the Data Privacy Act
and the Data Privacy Policies of the Department.

This information shall be stored and held confidentially in accordance with the provisions of the
Basic Education Act and may only be shared with other government agencies or third parties subject to
Data sharing agreements and data privacy requirements for legitimate purposes only.

For inquiries, requests and concerns regarding your data privacy rights, please contact the data
privacy compliance officer, team of the school, schools division office or regional office concerned.

I hereby authorize the Department of Education to use, collect, and process the information for
the purposes of the above stated.
Name and Signature of Child Name and Signature of Parent
SHD Form 1-A

Name : ________________________________________ LRN : ______________________

Medical History (For Learners)

1. Do you have any allergies? Yes No

If Yes, please identify below:
__ Medicine
__ Pollens
__ Food
__ Stinging Insects
__ Others:

2. Do you have any ongoing medical condition? Yes No

If Yes, please identify below:
__ Error of refraction
__ Asthma
__ Seizure
__ Heart problem
__ Anemia
__ Bleeding disorder
__ Hernia (painful bulge in the groin area)
__ Others:

3. Have you ever had surgery/ hospitalization? Yes No

If Yes, please identify below:

4. Does anyone in your family have the following conditions:

__ Tuberculosis
__ Cancer If yes, what kind?
__ Stroke
__ Diabetes Mellitus
__ Hypertension
__ Depression
__ Others______________________________________

5. Exposure to cigarette/vape smoke at home? Yes No

I certify that the above information are correct.

Name & Signature of Parent/Guardian Date

SHD Form 1-B

Name : ________________________________________ LRN : ___________________________

Medical/Nursing Findings

GRADE 1 /SPED GR 2/SPED GR 3 / SPED GR 4 / SPED GR5 / SPED GR 6 / SPED

KINDER / SPED GRADE 7 GR 8 GR 9 GR 10 GR 11 GR 12
Findings Findings Findings Findings Findings Findings Findings
Date of Examination
Height (in cm)
Weight (in kg)
Nutritional Status (NS) (BMI/Wt-for-Age)
Nutritional Status (NS) (Height-for-Age)
4Ps Beneficiary (√ or X)
SBFP Beneficiary (√ or X)
Deworming (√ or X) Sept March Sept March Sept Mar Sept March Sept Mar Sept Marc Sept March

Iron Supplementation (√ or X)
Immunization (Specify what kind)
Menarche
Temperature/BP
Heart Rate/Pulse Rate/Respiratory Rate
Vision Screening using appropriate chart
Auditory Screening (Tuning Fork)
Skin/ Scalp
Eyes/Ears/Nose
Mouth/Throat/Neck
Lungs/Heart
Abdomen
Deformities
Others, specify
Examined by: _________________________________ Designation: _________________________________
LEGEND:

NS Vision/ Auditory Skin/Scalp Eye/Ear/Nose Mouth/Neck/Throat Heart/Lungs Abdomen Deformities

Screening
a. Normal Weight Vision a. Normal a. Normal a. Normal a. Normal a. Normal a. Acquired
b. Wasted a. Passed L R b. Presence of Lice b. Inflamed Eye Lid b. Enlarged tonsils b. Rales b. Distended (Specify)
c. Severely b. Failed L R c. Redness of Skin c. Eye Redness c. Presence of lesions c. Wheeze c. Abdominal Pain b. Congenital
Wasted/Underwt
d. Overweight d. White Spots d. Occular d. Inflamed pharynx d. Murmur d. Tenderness (Specify)
Auditory Misalignment
e. Obese a. Passed L R e. Flaky Skin/ scalp e. Pale Conjunctiva e. Enlarged lymphnodes e. Irregular heart e. Dysmenorrhea c. none
rate
f. Normal Height b. Failed L R f. Impetigo/boil f. Matted Eyelashes f. Others , specify f. colds f. Others, Specify
g. Stunted g. Hematoma g. Eye Discharge (Dental caries/prob) g. Cough
h. Severely Stunted Others: h. Bruises/ Injuries h. Ear discharge h. Others, specify
i. Tall c. with visual i. Itchiness i. Impacted cerumen ( with presribed meds
impairment for heart/lungs)

d. hearing impairment j. Skin Lessions j. Mucus discharge

k. Acne/Pimple k. Nose Bleeding

l. Capillary refill (Epistaxis)
l. Others, specify
greater than 3
m. others, specify
seconds
Note: Use Letter to record ailments and Place X if not examined

Medical Treatment Record

Date Chief Complaint Intervention/Treatment Done Remarks Attended by

(Name/Position)
SHD Form 1-B

Name : ________________________________________ LRN : ___________________________

Medical/Nursing Findings

KINDER /SPED
GR 1 /SPED GR GR 2/SPED GR 3 / SPED GR 4 /SPED GR5 / SPED GR 6 /SPED
7 GR 8 GR 9 GR 10 GR 11 GR 12
Findings Findings Findings Findings Findings Findings Findings
Date of Examination
Height (in cm)
Weight (in kg)
Nutritional Status (NS) (BMI/Wt-for-Age)
Nutritional Status (NS) (Height-for-Age)
4Ps Beneficiary (√ or X)
SBFP Beneficiary (√ or X)
Deworming (√ or X) Sept March Sept March Sept Mar Sept March Sept Mar Sept Marc Sept March
Iron Supplementation (√ or X)
Immunization (Specify what kind)
Menarche
Temperature/BP
Heart Rate/Pulse Rate/Respiratory Rate
Vision Screening using appropriate chart
Auditory Screening (Tuning Fork)
Skin/ Scalp
Eyes/Ears/Nose
Mouth/Throat/Neck
Lungs/Heart
Abdomen
Deformities
Others, specify
Examined by:
LEGEND:

NS Vision/ Auditory Skin/Scalp Eye/Ear/Nose Mouth/Neck/Throat Heart/Lungs Abdomen Deformities

Screening
a. Normal Weight Vision a. Normal a. Normal a. Normal a. Normal a. Normal a. Acquired
b. Wasted a. Passed L R b. Presence of Lice b. Inflamed Eye Lid b. Enlarged tonsils b. Rales b. Distended (Specify)
c. Severely b. Failed L R c. Redness of Skin c. Eye Redness c. Presence of lesions c. Wheeze c. Abdominal Pain b. Congenital
Wasted/Underwt
d. Overweight d. White Spots d. Occular d. Inflamed pharynx d. Murmur d. Tenderness (Specify)
Auditory Misalignment
e. Obese a. Passed L R e. Flaky Skin/ scalp e. Pale Conjunctiva e. Enlarged lymphnodes e. Irregular heart rate e. Dysmenorrhea c. none

f. Normal Height b. Failed L R f. Impetigo/boil f. Matted Eyelashes f. Others , specify f. colds f. Others, Specify
g. Stunted g. Hematoma g. Eye Discharge (Dental caries/prob) g. Cough
h. Severely Stunted Others: h. Bruises/ Injuries h. Ear discharge h. Others, specify
i. Tall c. with visual i. Itchiness i. Impacted cerumen ( with presribed meds
impairment/ with for heart/lungs)
eyeglasses

d. hearing impairment j. Skin Lessions j. Mucus discharge

k. Acne/Pimple k. Nose Bleeding

l. Capillary refill (Epistaxis)
l. Others, specify
greater than 3
m. others, specify
seconds
Note: Use Letter to record ailments and Place X if not examined

Medical Treatment Record

Date Chief Complaint Intervention/Treatment Done Remarks Attended by

(Name/Position)
SHD Form 1-B

Name : ________________________________________ LRN : ___________________________

Medical/Nursing Findings

GRADE 7 GRADE 8 GRADE 9 GRADE 10 GRADE 11 GRADE 12 REMARKS

Findings Findings Findings Findings Findings Findings

Date of Examination
Height (in cm)
Weight (in kg)
Nutritional Status (NS) (BMI/Wt-for-Age)
Nutritional Status (NS) (Height-for-Age)
4Ps Beneficiary (√ or X)
SBFP Beneficiary (√ or X)
Sept March Sept March Sept Mar Sept March Sept Mar Sept Mar
Deworming (√ or X)

Iron Supplementation (√ or X)
Immunization (Specify what kind)
Menarche
Temperature/BP
Heart Rate/Pulse Rate/Respiratory Rate
Vision Screening using appropriate chart
Auditory Screening (Tuning Fork)
Skin/ Scalp
Eyes/Ears/Nose
Mouth/Throat/Neck
Lungs/Heart
Abdomen
Deformities
Others, specify

Examined by: _________________________________ Designation: _________________________________

LEGEND:
Vision/ Auditory
NS Skin/Scalp Eye/Ear/Nose Mouth/Neck/Throat Heart/Lungs Abdomen Deformities
Screening
a. Normal Weight Vision a. Normal a. Normal a. Normal a. Normal a. Normal a. Acquired
(Specify)
b. Wasted a. Passed L R b. Presence of b. Inflamed Eye Lid b. Enlarged tonsils b. Rales b. Distended
c. Severely L R Lice
c. Redness of Skin c. Abdominal Pain b. Congenital
Wasted/Underwt b. Failed c. Eye Redness c. Presence of lesions c. Wheeze (Specify)

d. Overweight d. White Spots d. Occular d. Inflamed pharynx d. Murmur d. Tenderness

Auditory Misalignment
e. Obese a. Passed L R e. Flaky Skin e. Pale Conjunctiva e. Enlarged lymphnodes e. Irregular heart e. Dysmenorrhea
rate
f. Normal Height b. Failed L R f. Impetigo/boil f. Matted Eyelashes f. Others , specify f. colds f. Others, Specify
g. Stunted g. Hematoma g. Eye Discharge g. Cough
h. Severely h. Bruises/
Stunted Injuries h. Ear dischrage h. Others, specify
i. Tall i. Itchiness i. Impacted
cerumen
j. Skin Lessions j. Mucus discharge
k. Acne/Pimple k. Nose Bleeding
(Epistaxis)

l. Capillary refill l. Others, specify

greater than 3
seconds
m. others, specify
Note: Use Letter to record ailments and Place X if not examined
SHD Form 1-B

Name : ________________________________________ LRN : _______________________________________

Medical/Nursing Findings
Kinder/ Grade 1/ Grade 2/ Grade 3/ Grade 4/ Grade 5/ Grade 6/ Grade 7/ Grade 8/ Grade 9/ Grade 10/ Grade 11/ Grade 12/
SPED SPED SPED SPED SPED SPED SPED SPED SPED SPED SPED SPED SPED

Findings

Findings

Findings

Findings

Findings

Findings

Findings

Findings

Findings

Findings

Findings

Findings

Findings
Date of Examination

Height (in cm)

Weight (in kg)

Nutritional Status (NS) (BMI/Wt-for-Age)

Nutritional Status (NS) (Height-for-Age)

4Ps Beneficiary (√ or X)

SBFP Beneficiary (√ or X)
Jul Jan Jul Jan Jul Jan Jul Jan Jul Jan Jul Jan Jul Jan Jul Jan Jul Jan Jul Jan Jul Jan Jul Jan Jul Jan
Deworming (√ or X)

Iron Supplementation (√ or X)

Immunization (Specify what kind)

Menarche

Temperature/BP

Heart Rate/Pulse Rate/Respiratory Rate

Vision Screening using appropriate chart

Auditory Screening (Tuning Fork)

Skin/ Scalp

Eyes/Ears/Nose

Mouth/Throat/Neck

Lungs/Heart

Abdomen

Deformities

Others, specify

Examined by: _________________________________ Designation: _________________________________

LEGEND:

Vision/ Auditory
NS Skin/Scalp Eye/Ear/Nose Mouth/Neck/Throat Heart/Lungs Abdomen Deformities
Screening
a. Normal Weight a. Normal a. Normal a. Normal a. Normal a. Normal a. Acquired
Vision (Specify)
b. Wasted a. Passed L R b. Presence of Lice b. Inflamed Eye Lid b. Enlarged tonsils b. Rales b. Distended

c. Severely b. Failed L R c. Redness of Skin c. Eye Redness c. Presence of lesions c. Wheeze c. Abdominal Pain b. Congenital
Wasted/Underwt (Specify)
d. Overweight d. White Spots d. Ocular Misalignment d. Inflamed pharynx d. Murmur d. Tenderness
Auditory

e. Obese a. Passed L R e. Flaky Skin e. Pale Conjunctiva e. Enlarged lymphnodes e. Irregular heart rate e. Dysmenorrhea

f. Normal Height b. Failed L R f. Impetigo/boil f. Others , specify f. Others, Specify

f. Matted Eyelashes f. colds

g. Stunted g. Hematoma g. Eye Discharge g. Cough

h. Severely Stunted h. Bruises/ Injuries h. Ear dischrage h. Others, specify

i. Tall i. Itchiness i. Impacted cerumen

j. Skin Lessions j. Mucus discharge

k. Acne/Pimple k. Nose Bleeding

(Epistaxis)
l. Capillary refill l. Others, specify
greater than 3
seconds
 m. others, specify

Note: Use Letter to record ailments and Place X if not examined

SHD Form 1-C

Name : ____________________________________________ LRN : __________________________________

Medical Treatment Record

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

2
2
SHD Form 1-D
Name : ____________________________________________ LRN : __________________________________
Dental Findings
Medical History Guide Questions
Yes No Remarks Do you have a toothbrush? Y N
Allergy How many times do you brush your teeth?
Asthma How many times do you change your toothbrush in a year?
Anemia Do you use toothpaste in brushing?
Bleeding problem How many times do you visit the dentist in a year?
Health Ailment
Diabetes Intervention/Treatment Record
Epilepsy Date Chief Complaint Intervention/Treatment Done Remarks Attended by
(Name/Position)
Kidney Disease
Convulsion
Fainting
KINDER S.Y. GRADE 1 /GRADE 7 S.Y.
TEMPORARY T dft index
RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT
Index d.f.t. k 1 2 3 4 5 6
TEMPORARY TEETH TEMPORARY TEETH
No. T / decaye
No. T / filled
PERMANENT TEETH

PERMANENT TEETH
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 Total d.f.t.

For Extraction
For Filling

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 Total Sound te

TEMPORARY TEETH TEMPORARY TEETH PERMANENT TEETH

RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT 1 2 3 4 5 6

Index D.M.F.T. k
7 8 9 10 11 12
GRADE 2/ GRADE 8 S.Y. GRADE 3 /GRADE 9 S.Y. No. T / decayed
No. T / Missing
RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT No. T. / Filled

TEMPORARY TEETH TEMPORARY TEETH Total D.M.F.T.

For Extraction
For Filling
PERMANENT TEETH

PERMANENT TEETH

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 Total Sound 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 SYMBOL FOR MOUTH EXAMINATION

X - Carious tooth indicated for extraction
D - Carious tooth indicated for filling
TEMPORARY TEETH TEMPORARY TEETH RF - Root fragment

RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT O - Missing tooth

F2 - Permanently filled tooth with
GRADE 4 / GRADE 10 S.Y. GRADE 5 /GRADE 11 S.Y. recurrence of decay

RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT

TEMPORARY TEETH TEMPORARY TEETH (ü) - Sound/erupted Permanent/Temp tooth
PFS - Pit and Fissure Sealant
JC - Jacket Crown
PERMANENT TEETH

PERMANENT TEETH

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 P - Pontic
RPD- Removable Partial Denture

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 FB - Fixed Bridge
CD - Complete Denture
GI - Glass Ionomer
TEMPORARY TEETH TEMPORARY TEETH SyF - Composite
RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT RIGHT 85 84 p 82 81 71 72 73 74 75 LEFT AgF - Amalgan

GRADE 6 / GRADE 12 S.Y. ORAL HEALTH CONDITION

1 2 3 4 5 6
Kinder
7 8 9 10 11###
RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT Gingivitis
TEMPORARY TEETH Periodontal Disease
Malocclussion
Supernumerary teeth
PERMANENT TEETH

18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 Retained decidous teeth

Decubital ulcer
Calculus
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 Cleft lip / palate
Root fragment
Fluorosis

TEMPORARY TEETH Others, Specify

RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT

SHD Form 1-Db

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###
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 (ü) - Sound/erupted Permanent/Temporary 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
O - Missing tooth P - Pontic SyF - Composite
F2 - Permanently filled tooth with RPD - Removable Partial Denture AgF - Amalgan
recurrence of decay
Intervention/Treatment Record
Date Chief Complaint Intervention/Treatment Done Remarks Attended by (Name/Position)

2
SHD Form 1-D

Name : ____________________________________________ LRN : __________________________________

Dental Findings

Medical History Guide Questions

Yes No Remarks Do you have a toothbrush? Y N

Allergy How many times do you brush your teeth?

Asthma How many times do you change your toothbrush in a year?

Anemia Do you use toothpaste in brushing?

Bleeding problem How many times do you visit the dentist in a year?

Health Ailment

Diabetes

Epilepsy

Kidney Disease

Convulsion

Fainting

KINDER S.Y. GRADE 1 S.Y.

RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT

TEMPORARY TEETH TEMPORARY TEETH

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
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

TEMPORARY TEETH TEMPORARY TEETH

RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT

GRADE 2 S.Y. GRADE 3 S.Y.

RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT

TEMPORARY TEETH TEMPORARY TEETH

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
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

TEMPORARY TEETH TEMPORARY TEETH

RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT

2
SHD Form 1-Da

Name : ____________________________________________ LRN : __________________________________

GRADE 4 / GRADE 10 S.Y. GRADE 5 / GRADE 11 S.Y.

RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT

TEMPORARY TEETH TEMPORARY TEETH

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
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

TEMPORARY TEETH TEMPORARY TEETH

RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT

GRADE 6 / GRADE 12 S.Y. ORAL HEALTH CONDITION

1 2 3 4 5 6
Kinder 7 8 9 10 11 12
RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT Gingivitis
TEMPORARY TEETH Periodontal Disease
Malocclussion
Supernumerary teeth
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 Retained decidous teeth
PERMANENT TEETH

Decubital ulcer
Calculus
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 Cleft lip / palate
Root fragment
Fluorosis
TEMPORARY TEETH Others, Specify
RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT

SHD Form 1-Db

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 (ü) - Sound/erupted Permanent/Temporary 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
O - Missing tooth P - Pontic SyF - Composite
F2 - Permanently filled tooth with RPD - Removable Partial Denture AgF - Amalgan
recurrence of decay
Intervention/Treatment Record
Date Chief Complaint Intervention/Treatment Done Remarks Attended by (Name/Position)

3
SHD Form 1-Db

Name : ____________________________________________ LRN : __________________________________

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 (ü) - Sound/erupted Permanent/Temporary 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
O - Missing tooth P - Pontic SyF - Composite
F2 - Permanently filled tooth with RPD - Removable Partial Denture AgF - Amalgan
recurrence of decay

Intervention/Treatment Record

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