___ History of Previous Hospitalization: File No.

_______
Medical (Last Admission & Cause) _________________________________
Surgical (Post-Operative) ________________________________________
___ Blood transfusion (Month & Year) ________________________________ Republic of the Philippines
___Tattoo Department of Health
___ Others (Please specify) _________________________________________ Regional Office III

(Municipality/City/Province)

Conforme:
Individual Patient Treatment Record
Patient’s / Guardian’s Name and Signature
Dietary Habits / Social History Name
Surname First Name Middle Initial
___ Sugar Sweetened Beverages/Food (Amount, Frequency & Duration ________
___ Use of Alcohol (Amount, Frequency & Duration) ________________________ Date of Birth __________________________________________________
___ Use of Tobacco (Amount, Frequency & Duration) _______________________ Place of Birth Age Sex
___ Betel Nut Chewing (Amount, Frequency & Duration) ____________________ Address
Occupation
Oral Health Condition Parent/Guardian
A. Check () if present () if absent
Date of Oral Examination Other Patient Information (Membership)
Orally Fit Child (OFC) ___ National Household Targeting System – Poverty Reduction (NHTS-PR)
Dental Caries ___ Pantawid Pamilyang Pilipino Program (4Ps)
Gingivitis ___ Indigenous People (IP)
Periodontal Disease ___Person With Disabilities (PWDs)
Debris
___PhilHealth (Indicate Number)
Calculus
___SSS (Indicate Number)
Abnormal Growth
___GSIS (Indicate Number)
Cleft Lip / Palate
Others
(supernumerary/mesiodens, Vital Signs
malocclusions, etc.) Blood Pressure: _____________ Pulse Rate: ___________________
B. Indicate Number Temperature: _______________
No. of Perm. Teeth Present
No. of Perm. Sound Teeth Medical History
No. of Decayed Teeth (D) ___ Allergies (Please specify) ________________________________________
No. of Missing Teeth (M) ___ Hypertension/ CVA
No. of Filled Teeth (F) ___ Diabetes Mellitus
Total DMF Teeth ___ Blood Disorders
No. of Temp. Teeth Present ___ Cardiovascular / Heart Diseases
No. of Temp. Sound Teeth ___ Thyroid Disorders
No. of Decayed Teeth (d)
___ Hepatitis (Please specify type) _0__________________________________
No. of Filled Teeth (f)
___ Malignancy (Please specify) ______________________________________
Total df Teeth
 __
A. Oral Health Condition
00
Year I - Date Year II- Date Year III - Date
Treatment Treatment Treatment

Condition Condition Condition

Condition Condition Condition

Treatment Treatment Treatment

Legend: Condition Legend: Treatment

Year IV - Date Year V - Date Capital letters shall be used for recording Topical Fluoride Application:
Treatment
Treatment the condition of permanent dentition and
small letters for the status of temporary FV – Fluoride Varnish
dentition. FG – Fluoride Gel
Permanent Tooth Temporary
Condition PFS – Pit and Fissure Sealant
Condition Condition
 Sound/Sealed 
PF – Permanent Filling
D Decayed d
(Composite, Am, ART)
F Filled f
M Missing e TF – Temporary Filling
DX Indicated for dx
Condition Condition X – Extraction
Extraction
Un Unerupted un O – Others
S Supernumerary s
Treatment Treatment Tooth
JC Jacket Crown jc
P Pontic
Blue for F/f Red for p
Color Code: D/d
Red for D/d Blue for f/F Red for d/D
B. Services Monitoring Chart
Date Fluoride Varnish/Fluoride Gel, Pit and Fissure Sealant, Permanent Filling, Temporary Filling, Extraction Legend:
Topical Fluoride Application:
FV – Fluoride Varnish
FG – Fluoride Gel
55 54 53 52 51 61 62 63 64 65
PFS – Pit and Fissure Sealant
PF – Permanent Filling (Composite, Am, ART)
TF – Temporary Filling
X – Extraction
85 84 83 82 81 71 72 73 74 75 O – Others

Date Fluoride Varnish/Fluoride Gel, Pit and Fissure Sealant, Permanent Filling, Temporary Filling, Extraction

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

48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
 Individual Patient Treatment
Record of Services Rendered
For Oral Prophylaxis, Fluoride Varnish/Gel - Check () if rendered
For Permanent & Temporary Filling, Pit and Fissure Sealant and Extraction - Indicate Number
Fluoride
Pit and Fissure Permanent Temporary Remarks / Others (Specify) Dentist’s
Oral Prophylaxis Varnish/ Extraction Consultation
Date Sealant Filling Filling Signature
Fluoride Gel