2018 SHD Form 2

INTERVENTION/TREATMENT RECORD
Date Chief Complaint Intervention/Treatment Done Remarks

SCHOOL ORAL HEALTH EXAMINATION CARD

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

RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT RIGHT 55 54 53 52

TEMPORARY TEETH TEMPORARY TEETH
PERMANENT TEETH

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

48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 48 47 46 45 44 43 42

TEMPORARY TEETH TEMPORARY TEETH

RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT RIGHT 85 84 83 82

GRADE 2/GRADE 9 S.Y. GRADE 3/GRADE 10 S.Y.

RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT RIGHT 55 54 53 52

TEMPORARY TEETH TEMPORARY TEETH
PERMANENT TEETH

PERMANENT TEETH

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

48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 48 47 46 45 44 43 42

TEMPORARY TEETH TEMPORARY TEETH

RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT RIGHT 85 84 83 82

GRADE 4/GRADE 11 S.Y. GRADE 5/GRADE 12

RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT RIGHT 55 54 53

TEMPORARY TEETH TEMPORARY TEETH
PERMANENT TEETH

PERMANENT TEETH

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

48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 48 47 46 45 44 43

TEMPORARY TEETH TEMPORARY TEETH

RIGHT 85 84 83 82 81 71 72 73 74 75 LEFT RIGHT 85 84 83

GRADE 6/ S.Y. ORAL HEALTH CONDITION

Kinder
RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT Gingivitis
TEMPORARY TEETH Periodontal Disease
Malocclussion
NENT TEETH

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 2018 SHD Form 2
PERMANENT TEETH

Supernumerary teeth
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 Retained decidous 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.
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
D - Carious tooth indicated for filling PFS - Pit and Fissure Sealant
RF - Root fragment JC - Jacket Crown
M - Missing tooth PFS - Pontic
F2 - Permanently filled tooth with RPD - Removable Partial Denture
recurrence of decay
INTERVENTION/TREATMENT RECORD
Date Chief Complaint Intervention/Treatment Done Remarks

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 2018 SHD Form 2

marks Attended by (Name/Position)

51 61 62 63 64 65 LEFT

11 21 22 23 24 25 26 27 28

41 31 32 33 34 35 36 37 38

81 71 72 73 74 75 LEFT

51 61 62 63 64 65 LEFT

11 21 22 23 24 25 26 27 28

41 31 32 33 34 35 36 37 38

81 71 72 73 74 75 LEFT

S.Y.

52 51 61 62 63 64 65 LEFT

12 11 21 22 23 24 25 26 27 28

42 41 31 32 33 34 35 36 37 38

82 81 71 72 73 74 75 LEFT

nder 1 2
8
3 4
10
5
11
6
7 9 12

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 2018 SHD Form 2

Kinder 1
7
2
8
3
9
4
10
5
11
6
12

FB - Fixed Bridge
CD - Complete Denture
GI - Glass Ionomer
CO - Composite
AM - Amalgan

marks Attended by (Name/Position)