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Republic of the Philippines DEPARTMENT OF EDUCATION 1 Region LA UNION Division DENTAL HEALTH RECORD 9-Dec-14 Date Name: CHRIS JOHN R. MAQUI Age: 11 Sex MALE Birth Date ### Event: OLLEYBALL BOYS arent/Guardian: ESAR B. MAQUI Coach: GINGIVITIS 55 54 53 52 51 61 62 63 64 65 MALOCCLUSION 18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 DECUBITAL ULCER 48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CALCULUS CLEFT PALATE ROOT FRAGMENT FLUOROSIS 85 84 83 82 81 71 72 73 74 75 OTHERS (Specify) DAT YEAR LEVEL REMARKS TEMPORARY TEETH DATE INDEX D.F.T. EXAMINATION NO. T /DECAYED SEALANT (GI) NO. T/ FILLED PERMANENT FILLING TOTAL D.F.T. ART EXTRACTION TEMPORARY TEETH ORAL PROPHYLAXIS INDEX D.F.T. REFERRAL NO. T /DECAYED OTHER ORAL TREATMENT NO. T/MISSING NO. T/ FILLED TOTAL D.F.T. TOTAL SOUND TEETH SYMBOLS FOR MOUTH EXAMINATION SYMBOLS FOR ACCOMPLISHME X - TOOTH INDICATED DU - DECUBITAL ULCER Xt - EXTRACTED PERMAN FOR EXTRACTION MAL - MALOCLUSSION xt - EXTRACTED TEMPOR F - TOOTH INDICATED FLU - FLOUROSIS Am - AMALGAM FILLING FOR FILLING Gn - NORMAL Com - COMPOSITE FILLIN - TOOTH WITH TEMPORARY Gm - MODERATE GINGIVITIS FILLING (1-2 QUADRANTS) ARTIFICIAL RESTORATION RC - RECURRENT CARIES Gs - SEVERE GINGIVITIS JC - JACKET CROWN RF - ROOT FRAGMENT (3-4 QUADRANTS) I - INLAY M - MISSING TOOTH CMR - COMPLETE MOUTH REHAB OP - ORAL PROPHYLAXIS (√) - SOUND ERUPTED PERMANENT ZOE - ZINC OXIDE UEGEN TOOTH TF - TEMPORARY FILLIN R - REFERRED TO PRIV UN - UNERUPTED PRERIODICAL DISEASE SUPERNUMERARY TOOTH RETAINED DECIDOUS TEETH HEAVY SHADE PERMANENT TEETH CONDITION TREATMENT NEEDS LEFT RIGHT CONDITION TEMPORARY TEETH TEMPORARY TEETH RIGHT CONDITION LEFT CONDITION AND TREATMENT NEEDS Latest 1½ x Division Meet

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Dental Certificate

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Republic of the Philippines

DEPARTMENT OF EDUCATION1

Region

LA UNIONDivision

DENTAL HEALTH RECORD

9-Dec-14Date

Name: CHRIS JOHN R. MAQUI

Age: 11 Sex MALE Birth Date ###

Event: VOLLEYBALL BOYS

Parent/Guardian: CESAR B. MAQUI

Coach:

GINGIVITIS

55 54 53 52 51 61 62 63 64 65MALOCCLUSION

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

DECUBITAL ULCER48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CALCULUS

CLEFT PALATE

ROOT FRAGMENTFLUOROSIS

85 84 83 82 81 71 72 73 74 75 OTHERS (Specify)

DATE OF VISITYEAR LEVEL REMARKS TEMPORARY TEETH

DATE INDEX D.F.T.EXAMINATION NO. T /DECAYEDSEALANT (GI) NO. T/ FILLEDPERMANENT FILLING TOTAL D.F.T.ARTEXTRACTION TEMPORARY TEETHORAL PROPHYLAXIS INDEX D.F.T.REFERRAL NO. T /DECAYEDOTHER ORAL TREATMENT NO. T/MISSING

NO. T/ FILLEDTOTAL D.F.T.TOTAL SOUND TEETH

SYMBOLS FOR MOUTH EXAMINATION SYMBOLS FOR ACCOMPLISHMENTX - TOOTH INDICATED DU - DECUBITAL ULCER Xt - EXTRACTED PERMANENT TOOTH

FOR EXTRACTION MAL - MALOCLUSSION xt - EXTRACTED TEMPORARY TOOTHF - TOOTH INDICATED FLU - FLOUROSIS Am - AMALGAM FILLING

FOR FILLING Gn - NORMAL Com - COMPOSITE FILLING- TOOTH WITH TEMPORARY Gm - MODERATE GINGIVITIS

FILLING (1-2 QUADRANTS) ARTIFICIAL RESTORATIONRC - RECURRENT CARIES Gs - SEVERE GINGIVITIS JC - JACKET CROWNRF - ROOT FRAGMENT (3-4 QUADRANTS) I - INLAYM - MISSING TOOTH CMR - COMPLETE MOUTH REHAB OP - ORAL PROPHYLAXIS

(√) - SOUND ERUPTED PERMANENT ZOE - ZINC OXIDE UEGENOL FILLING TOOTH TF - TEMPORARY FILLING

R - REFERRED TO PRIVATE DENTISTUN - UNERUPTED

PRERIODICAL DISEASE

SUPERNUMERARY TOOTH

RETAINED DECIDOUS TEETH

HEAVY SHADE

PERMANENT TEETH

CONDITION

TREATMENT NEEDS

LEFTRIGHT

CONDITION

TEMPORARY TEETH

TEMPORARY TEETH

RIGHT

CONDITION

LEFT

CONDITION AND TREATMENT NEEDS

Latest 1½ x 1½ picture

Division Meet Remarks/Findings__________________________________________________________________________________ _____________________________________________ DENTIST

Division Meet Remarks/Findings__________________________________________________________________________________ _____________________________________________ DENTIST

Republic of the Philippines

DEPARTMENT OF EDUCATION

Region

Division

DENTAL HEALTH RECORD

DATE OF VISIT

SYMBOLS FOR ACCOMPLISHMENTEXTRACTED PERMANENT TOOTHEXTRACTED TEMPORARY TOOTH

ARTIFICIAL RESTORATION

ZINC OXIDE UEGENOL FILLING

REFERRED TO PRIVATE DENTIST

Latest 1½ x 1½ picture