Republic of the Philippines
Department of Education
Region IX, Zamboanga Peninsula
SCHOOL HEALTH AND NUTRITION SECTION
Dipolog City Schools Division
ORAL HEALTH EXAMINATION RECORD FOR TEACHING AND NON-TEACHING PERSONNEL
Name: ____________________________________ Age: ________________________ Gender: ______________________
Date of Birth: _______________________________ Marital Status: _______________
Region: ________Division: _____________________ District: _____________________ School: ______________________
Designation: ________________
Medical History
Hypertension
Epilepsy
Allergies
Diabetes
Bleeding Disorder
Cardio Vascular Dse.
Asthma
Others:
_______________________
Please Specify
DENTITION STATUS
INDEX : DMFT
No. of
T/Decayed
Status
18
17
16
15
14
13
12
11
21
22
23
24
25
26
27
28
X
F
No. of
T/Missing
No. of T/Filled
48
47
46
45
44
43
42
41
31
32
33
34
35
36
37
38
Total
Status
TREATMENT RECORD
DATE
TOOTH NO.
NATURE OF OPERATION
Periodical Condition:
Normal
DENTAL PROSTHESES
Denture wearer: Y
N
Gingivitis
Please Specify: _______________
Periodical Disease
Need for Denture: Y
Other Abnormal Conditions
________________________
Please Specify
Please Specify: _______________
SYMBOLS FOR MOUTH EXAMINATION
X–Carious tooth indicated for
extraction
F–Carious tooth indicated for filling
RF–Root fragment
O–Missing tooth
N
F2–Permanently filled tooth
with recurrence of decay
Heavily Shade-Permanent
filling
Outline of filing–tooth w/
temporary filling
Artificial Restoration:
JC-Jacket crown
AB-Abutment
P-Pontic
I-Inlay
RPD-Removable partial denture
FB-Fixed Bridge
CD-Complete Denture
REMARKS
DENTIST
Remarks: __________________
Remarks: __________________
Remarks: __________________
SYMBOLS FOR ACCOMPLISHMENT
OP-Oral Prophylaxis
X-Extracted Permanent tooth
Ag F-Amalgam Filling
Sy F-Synthetic Porcelain
GIC-glass ionomer cement
ZnO F-Zinc Oxide filling
R-Referred to private Dentist
TREATMENT RECORD
DATE
TOOTH NO.
NATURE OF
OPERATION
REMARKS
DENTIST