EARLY CHILDHOOD CARE AND DEVELOPMENT PROGRAM

CEBU CITY
SCHOOL YEAR _________________________
NAME: _________________________________________________________________________________________________________________________
(SURNAME) (FIRST NAME) (MIDDLE NAME)
CITY:
___________________________________________________________________________________________________________________________
(BARRIO/BARANGAY) (NO./SCHOOL/FIRM)

PROVINCE: _____________________________________________________ HOSPITAL:

__________________________________________________

IN PATIENT REPUBLIC OF THE PHILIPPINES PRE-SCHOOL

OUT PATIENT DEPARTMENT OF HEALTH SCHOOL CHILDREN
REGIONAL HEALTH OFFICE NO. _____ PRE-NATAL
ADULT

INDIVIDUAL DENTAL HEALTH RECORD

DATE OF BIRTH: _________________________________________________________ SEX: MALE FEMALE

ADDRESS: ______________________________________________________________ OCCUPATION: _________________________________________

OPERATION
CONDITION
55 54 53 52 51 61 62 63 64 65

RIGHT (LABIO BUCCAL) LEFT

OPERATION
CONDITION

UPPER 8 17 18 15 14 13 12 11 21 22 23 24 25 26 27 28
LOWER 48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38

CONDITION
OPERATION

(LABIO BUCCAL)

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

DATE OF EXAMINATION
AGE LAST BIRTHDAY
PRESENCE OF DENTAL CARIES YN YN YN YN YN YN YN
PRESENCE OF GINGIVITIES
PRESENCE OF PERICDENTAL POCKET
PRESENCE OF ORAL DEBRIS
PRESENCE OF CACULUS
PRESENCE OF NEOPLASM
PRESENCE OF DENTO-FACIAL ANOMALLY
TOOTH COUNT

T P T P T P T P T P T P
NUMBER OF TEETH PRESENT D
CARIES INDICATED FOR FILING
CARIES INDICATED FOR EXTRACTION DECAY
ROOT FRAGMENT
MISSING DUE TO CARRIES M
FILLED OR RESTTORED F
TOTAL OF AND DMF TEETH
FLOURIDE APPLICATION
EXAMINER

LEGEND:

CONDITION G-GOLD CROWN S-SILICATE FILLING

J-JACKET CROWN X-EXTRACTION DUE TO CARIES
/-CARIES FREE
AB-ABUTMENT XO-EXTRACTION DUE TO OTHER CAUSES
D-CARIES INDICATED FOR FILLING
P-PONIC C-CEMENT FILLING
\-CARIES INDICATED FOR EXTRACTION
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I-INLAY
R-ROOT FRAGMENT
FX-FIXED BRIDGE
M-MISSING DUE TO CARIES
RM-REMOVAL BRIDGE
MD-MISSING DUE TO OTHER CAUSES
FD-FULL DENTURE
F-FILLED OR RESTORED
U-UNERUPTED

OPRERATION
RESTORATION & PROSTHETIC
A-AMALGAM FILING
APPLICATION