Republic of the Philippines

Department of Education
REGION X- NORTHERN MINDANAO
DIVISION OF MALAYBALAY CITY
Individual Treatment Record - Dental

Name: _________________________________________________________________ Do you have a toothbrush? Yes____ No____

Surname First Name M.I. How many times do you brush your teeth? __________________
Date of Birth: ____________________________ Age ___________ Sex__________ How many times do you change your toothbrush in a year? ____________________
Place of Birth ___________________________________________________________________ Do you use toothpaste in brushing? Yes ____ No ____
Address: _______________________________________________________________________ How many times do you visit the dentist in a year? ___________
______________________________________________________________________
Parent/Guardian_________________________________________________________________ TEMPORARY TEETH: dft Index
Index dft Kinder 1 2 3 4 5 6
Vital Signs
decayed
Blood Pressure________ Temperature__________ Pulse Rate_________________
filled
Medical History
Total dft

Yes No Remarks For Exo

Allergy For Filling
Asthma Total No. of Sound
Anemia teeth
Bleeding Problem
PERMANENT TEETH: DMFT Index
Heart Ailment
Diabetes Index DMFT
Kin
1 2 3 4 5 6 7 8 9 10 11 12
Epilepsy der

Kidney Disease Decayed

Convulsion
Missing
Fainting
Filled
Dietary Habits/Social History (Please Indicate amount, frequency and Duration)
Total DMFT
Yes No Remarks
Sugar rich food/drinks For Exo
Alcohol
For Filling
Tobacco
Drugs Total No. of
Betel Nut Sound teeth

ORAL HEALTH CONDITION

Guide Questions:

Purok 6, Casisang, Malaybalay City Document No. : FM-SCH-04 Eff. Date : 06-04-21
Telefax (088) 314-0094
Email: malaybalay.city@deped.gov.ph Revision No. : 00 Pages : 1 of 3
 Republic of the Philippines
Department of Education
REGION X- NORTHERN MINDANAO
DIVISION OF MALAYBALAY CITY
Individual Treatment Record - Dental

Grade: Grade:

Grade: Grade: Legend:

Tooth
Permanent Temporary
Condition
√ Sound/Sealed √
D Decayed d
F Filled f
M Missing e
Indicated for
DX dx
Extraction
Un Unerupted un
RF Root Fragment rf
JC Jacket Crown jc
Date of Examination P Pontic p
Orally Fit Child
Dental Caries A. Oral Health Condition: Check (√) if present (x) if absent
Gingivitis

Periodontal Disease
Grade:
Debris Purok 6, Casisang, Malaybalay City Document No. : FM-SCH-04 Eff. Date : 06-04-21
Calculus Telefax (088) 314-0094
Abnormal Growth Revision No. : 00 Pages : 2 of 3
Email: malaybalay.city@deped.gov.ph
Cleft Lip/Palate
Others (Mesiodens, Supernumerary,
Malocclusion
 Republic of the Philippines
Department of Education
REGION X- NORTHERN MINDANAO
DIVISION OF MALAYBALAY CITY
Individual Treatment Record - Dental

B. Intervention/Treatment Record
Attended by:
Date Chief Complaint Treatment Done Remarks
Name/Position

C. Service Monitoring Chart

Date 55 54 53 52 51 61 62 63 64 65
Date 85 84 83 82 81 71 72 73 74 75

Date 18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
Legend:
FV- Fluoride Varnish PFS- Pit and Fissure Sealant TF- Temporary Filling
FG- Fluoride Gel X- Extraction O- Others
ART- Atraumatic Treatment GI- Glass Ionomer OP- Oral Prophylaxis

Purok 6, Casisang, Malaybalay City DocumentDate

No. 48 47 : 46 FM-SCH-04
45 44 43 42 41 Eff.31Date32 33 :34 35 36
06-04-21 37 38

Telefax (088) 314-0094

Email: malaybalay.city@deped.gov.ph Revision No. : 00 Pages : 3 of 3