Republic of the Philippines

DEPARTMENT OF EDUCATION
Region XII
Division of South Cotabato
DANLAG NATIONAL HIGH SCHOOL
Brgy. Danlag, Tampakan, South Cotabato

DENTAL HEALTH RECORD Latest 1½ x 1½ picture

Name: DECIERDO, SAILENE W.
Age: 16 Sex FEMALE Birth Date 1-Jan-02 Date
Event: ATHLETICS SECONDARY GIRLS
DECIERDO, SAILENE W.
Parent/Guardian: GRADE X
Coach: SHIELA MAE CABASAG \

CONDITION AND TREATMENT NEEDS GINGIVITIS

PERIODONTAL
CONDITION
RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT DISEASE
TEMPORARY TEETH MALOCCLUSION
SUPERNUMERA
RY TOOTH
RETAINED
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 DECIDOUS
PERMANENT TEETH TEETH
DECUBITAL ULCER
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CALCULUS
CONDITION CLEFT PALATE
ROOT FRAGMENT
TREATMENT NEEDS
TEMPORARY TEETH
FLUOROSIS
RIGHT
85 84 83 82 81 71 72 73 74 75 LEFT
OTHERS (Specify)
CONDITION
DATE OF VISIT
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 ACCOMPLISHMENT
X - TOOTH INDICATED DU - DECUBITAL ULCER XT - EXTRACTED PERMANENT TOOTH
FOR EXTRACTION MAL - MALOCLUSSION xt - EXTRACTED TEMPORARY TOOTH
F - TOOTH INDICATED FLU - FLUOROSIS Am - AMALGAM FILLING
FOR FILLING Gn - NORMAL Com - COMPOSITE FILLING
HEAVY - TOOTH WITH TEMPORARY Gm - MODERATE GINGIVITIS
SHADE 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 UEGENOL FILLING
TOOTH TF - TEMPORARY FILLING
R - REFERRED TO PRIVATE DENTIST
UN - UNERUPTED TOOTH
Division Meet Remarks/Findings:

DENTIST
(signature over printed name)
PRC: LICENSE: Date Examined:
Regional Meet Remarks/Findings:

DENTIST
(signature over printed name)
PRC: LICENSE: Date Examined:
Palarong Pambansa Remarks/Findings:

DENTIST
(signature over printed name)
PRC: LICENSE: Date Examined:

FOR PALARONG PAMBANSA ONLY

 Republic of the Philippines
DEPARTMENT OF EDUCATION
Region XII
Division of South Cotabato
DANLAG NATIONAL HIGH SCHOOL
Brgy. Danlag, Tampakan, South Cotabato

DENTAL HEALTH RECORD

Latest 1½ x 1½ picture
Name: BALOLONG, VERGIE S.
Age: 15 Sex FEMALE Birth Date 21-Oct-02 Date
Event: ATHLETICS SECONDARY GIRLS
Parent/Guardian: BALOLONG, VIRGIE S.
Coach: SHIELA MAE CABASAG GRADE
\ X

CONDITION AND TREATMENT NEEDS GINGIVITIS

PERIODONTAL
CO
NDI
RIGH 55 54 53 52 51 61 62 63 64 65 LEF DISEASE
TIO
TEMPORARY
T T MALOCCLUSION
N
TEETH SUPERNUMERA
RY TOOTH
RETAINED
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 DECIDOUS
PER TEETH
MAN DECUBITAL ULCER
ENT
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 TEE CALCULUS
COTH CLEFT PALATE
NDI ROOT FRAGMENT
TIO
TREAT
TEMPORARY
N
MENT FLUOROSIS
TEETH 85 84 83 82 81 71 72 73 74 75 NEED OTHERS (Specify)
RIGH LEF S
T T
CON
DITI DATE OF VISIT
YEAR
ON 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 ACCOMPLISHMENT
X - TOOTH INDICATED DU - DECUBITAL ULCER XT - EXTRACTED PERMANENT TOOTH
FOR EXTRACTION MAL - MALOCLUSSION xt - EXTRACTED TEMPORARY TOOTH
F - TOOTH INDICATED FLU - FLUOROSIS Am - AMALGAM FILLING
FOR FILLING Gn - NORMAL Com - COMPOSITE FILLING
HEAVY - TOOTH WITH TEMPORARY Gm - MODERATE GINGIVITIS
SHADE 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 UEGENOL FILLING
TOOTH TF - TEMPORARY FILLING
R - REFERRED TO PRIVATE DENTIST
UN - UNERUPTED TOOTH
Division Meet Remarks/Findings:

DENTIST
(signature over printed name)
PRC: LICENSE: Date Examined:
Regional Meet Remarks/Findings:

DENTIST
(signature over printed name)
PRC: LICENSE: Date Examined:
Palarong Pambansa Remarks/Findings:

DENTIST
(signature over printed name)
PRC: LICENSE: Date Examined:

FOR PALARONG PAMBANSA ONLY

 Republic of the Philippines
DEPARTMENT OF EDUCATION
Region XII
Division of South Cotabato
DANLAG NATIONAL HIGH SCHOOL
Brgy. Danlag, Tampakan, South Cotabato

DENTAL HEALTH RECORD

Latest 1½ x 1½ picture
Name: SUSTIGUER, IAN C.
Age: 15 Sex MALE Birth Date 1-Jan-02 Date
Event: ATHLETICS SECONDARY BOYS
Parent/Guardian: SUSTIGUER, IAN C.
GRADE IX
Coach: MANILYN CIATA \

CONDITION AND TREATMENT NEEDS GINGIVITIS

PERIODONTAL
CO
NDI
RIGH 55 54 53 52 51 61 62 63 64 65 LEF DISEASE
TIO
TEMPORARY
T T MALOCCLUSION
N
TEETH SUPERNUMERA
RY TOOTH
RETAINED
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 DECIDOUS
PER TEETH
MAN DECUBITAL ULCER
ENT
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 TEE CALCULUS
COTH CLEFT PALATE
NDI ROOT FRAGMENT
TIO
TREAT
TEMPORARY
N
MENT FLUOROSIS
TEETH
RIGH
85 84 83 82 81 71 72 73 74 75 LEF
NEED
S
OTHERS (Specify)
T T
CON
DITI DATE OF VISIT
YEAR
ON 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 ACCOMPLISHMENT
X - TOOTH INDICATED DU - DECUBITAL ULCER XT - EXTRACTED PERMANENT TOOTH
FOR EXTRACTION MAL - MALOCLUSSION xt - EXTRACTED TEMPORARY TOOTH
F - TOOTH INDICATED FLU - FLUOROSIS Am - AMALGAM FILLING
FOR FILLING Gn - NORMAL Com - COMPOSITE FILLING
HEAVY - TOOTH WITH TEMPORARY Gm - MODERATE GINGIVITIS
SHADE 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 UEGENOL FILLING
TOOTH TF - TEMPORARY FILLING
R - REFERRED TO PRIVATE DENTIST
UN - UNERUPTED TOOTH
Division Meet Remarks/Findings:

DENTIST
(signature over printed name)
PRC: LICENSE: Date Examined:
Regional Meet Remarks/Findings:

DENTIST
(signature over printed name)
PRC: LICENSE: Date Examined:
Palarong Pambansa Remarks/Findings:

DENTIST
(signature over printed name)
PRC: LICENSE: Date Examined:

FOR PALARONG PAMBANSA ONLY

 Republic of the Philippines
DEPARTMENT OF EDUCATION
Region XII
Division of South Cotabato
DANLAG NATIONAL HIGH SCHOOL
Brgy. Danlag, Tampakan, South Cotabato

DENTAL HEALTH RECORD

Name: DECIERDO, SAILENE W.
Age: 16 Sex FEMALE Birth Date 1-Jan-02 Date
Event: ATHLETICS SECONDARY GIRLS
Parent/Guardian:
Coach: SHIELA MAE CABASAG \

CONDITION AND TREATMENT NEEDS GINGIVITIS

PERIODONTAL
CO
NDI
RIGH 55 54 53 52 51 61 62 63 64 65 LEF DISEASE
TIO
TEMPORARY
T T MALOCCLUSION
N
TEETH SUPERNUMERA
RY TOOTH
RETAINED
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 DECIDOUS
PER TEETH
MAN DECUBITAL ULCER
ENT
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 TEE CALCULUS
COTH CLEFT PALATE
NDI ROOT FRAGMENT
TIO
TREAT
TEMPORARY
N
MENT FLUOROSIS
TEETH
RIGH
85 84 83 82 81 71 72 73 74 75 LEF
NEED
S
OTHERS (Specify)
T T
CON
DITI DATE OF VISIT
YEAR
ON 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 ACCOMPLISHMENT
X - TOOTH INDICATED DU - DECUBITAL ULCER XT - EXTRACTED PERMANENT TOOTH
FOR EXTRACTION MAL - MALOCLUSSION xt - EXTRACTED TEMPORARY TOOTH
F - TOOTH INDICATED FLU - FLUOROSIS Am - AMALGAM FILLING
FOR FILLING Gn - NORMAL Com - COMPOSITE FILLING
HEAVY - TOOTH WITH TEMPORARY Gm - MODERATE GINGIVITIS
SHADE 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 UEGENOL FILLING
TOOTH TF - TEMPORARY FILLING
R - REFERRED TO PRIVATE DENTIST
UN - UNERUPTED TOOTH
Division Meet Remarks/Findings:

DENTIST
(signature over printed name)
PRC: LICENSE: Date Examined:
Regional Meet Remarks/Findings:

DENTIST
(signature over printed name)
PRC: LICENSE: Date Examined:
Palarong Pambansa Remarks/Findings:

DENTIST
(signature over printed name)
PRC: LICENSE: Date Examined:

FOR PALARONG PAMBANSA ONLY