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
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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
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