2018 SHD Form 2

REPUBLIC OF THE PHILIPPINES

DEPARTMENT OF EDUCATION
BUREAU OF LEARNER SUPPORT SERVICES - SCHOOL HEALTH DIVISION

SCHOOL ORAL HEALTH EXAMINATION CARD

Name: ESTREBILLA LEAN SHILOH SERRANO ### School ID: 112808
Last First Middle
LRN: 112808170022
Date of Birth: SEPTEMBER 4 2011 Region: V- BICOL
Month Day Year
Birthplace: QUEZON CITY Division: CAMARINES SUR
Parent/Guardian: LEIZEL B. ESTREBILLA Telephone No.:
Address: SAN JOSE, MINALABAC CAMARINES SUR

Medical History
Yes No Remarks
Allergy
Asthma Guide Questions
Anemia Do you have a toothbrush? Y ____ N ____
Bleeding Problem How many times do you brush your teeth? _______________
Health Ailment How many times do you change your toothbrush in a year? __________
Diabetes Do you use toothpaste in brushing? _____
Epilepsy How many times do you visit the dentist in a year? _______________
Kidney Disease
Convulsion
Fainting

KINDER S.Y. GRADE 1 / 7 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 / 8 S.Y. GRADE 3 / 9 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

1
2018 SHD Form 2

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

TEMPORARY TEETH dft index PERMANENT TEETH

Index d.f.t. Kinder 1 2 3 4 5 6 Index D.M.F.T. Kinder 1 2 3 4 5 6
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 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)