Republic of the Philippines

Department of Education
Division of Surigao del Sur
MADRID NATIONAL HIGH SCHOOL

ORAL HEALTH EXAMINATION RECORD FOR TEACHERS 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 Others:

Cardio Vascular Dis. Asthma

Please specify

DENTITION STATUS INDEX:DMFT

Status

Status

TREATMENT RECORD
DATE TOOTH NO. NATURE OF OPERATION REMARKS DENTIST

Periodontal Condition : Dental Prostheses: Remarks:

Y N
Normal Denture wearer
Gingivitis Please specify:
Y N
Periodontal Disease Need for Denture Remarks :
Other Abnormal Conditions Please specify : Remarks:
Please Specify
SYMBOLS FOR MOUTH EXAMINATION Artificial Restoration SYMBOLS FOR ACCOMPLISHMENT
X- carious tooth indicated for extraction F2- Permanently Filled tooth JC- Jacket Crown OP-Oral Prophylaxis
F-carious tooth indicated for filling with recurrence of decay AB-Abutment X-Extracted Permanent Tooth
RF-root fragment Heavy shade-Perm.Filling P-Pontic AgF- Amalgam Filling
O-missing tooth Outline of filling-tooth with RPD-Removable Partial Denture SyF- Synthetic Porcelain
temporary filling FB-Fixed Bridge GIC- Glass Ionomer Cementt
CD-Complete Denture ZnOF- Zinc Oxide Filling
R-Referred to private dentist
 TREATMENT RECORD

TOOTH
DATE NATURE OF OPERATION REMARKS DENTIST
NO.