REPUBLIC OF THE PHILIPPINES

DEPARTMENT OF EDUCATION
HEALTH AND NUTRITION CENTER
SCHOOOLS DIVISION OF NUEVA ECIJA

SCHOOL ORAL HEALTH EXAMINATION CARD

Elementary Questions
MEDICAL HISTORY
YES NO Guided Questions
Allergy
Asthma Do you have toothbrush _____ Y _____ N
Anemia
Bleedeing Problem How many times do you brush your teeth _____ once ___
Heart Ailment
Diabetes How many times do you change your toothbrush in a yea
Epilepsy
Kidney Disease Do you use toothpaste in brushing ? _____ Y _____ N
Convulsion
Fainting How many times do you visit the dentist in a year? _____

CONDITION AND TREATMENT NEEDS

CONDITION

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

TEMPORARY TEETH
PERMANENT TEETH

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

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

TEMPORARY TEETH

RIGHT LEFT

CONDITION 85 84 83 82 81 71 72 73 74 75

DENTAL PROCEDURES
Pre-Schooler 1 2 3 4 5 6 Remarks
DATE
Examination
Sealant (G.I.)
Gum Treatment
Permanent filling
ART
Extraction
Referral
Other and treatment

Examined by

SYMBOLS FOR MOUTH EXAMINATION

X - Tooth indicated for extraction
F - Tooth indicated for filling
Outline of filling - Tooth with
temporary filling
Heavy Shade - Permanent filling
RD - recurrence of decay
RF - Root fragment
M - Missing tooth
DU - Decubital ulcer
Mal - malocclusion
ME - Motted Enamel
Gn - Normal
Gm - moderate gingivitis (1-2 quadrant)
Gs - severe gingivitis (3-4 quadrant)
CMR - complete mouth rehab
(̷ ) Sound/erupted Permanent Tooth
Xt - Extracted permanent tooth
xt - Extracted temporary tooth
Ag F - Amalgam filling
Sy F - Synthetic filling
Artificial Restoration
JC - Jacket Crown
I - Inlay
 PPINES
CATION
CENTER
UEVA ECIJA

MINATION CARD

____ Y _____ N

rush your teeth _____ once _____ 2x _____ 3x

hange your toothbrush in a year? ________

brushing ? _____ Y _____ N

isit the dentist in a year? _____once _____ 2x

ORAL HEALTH CONDITION

Pre-Schooler 1 2 3 4 5 6
Gingivitis

Periodontal Disease

Malocclussion

Supernumerary teeth

Retained deciduous teeth

Decubital ulcer

Calculus

Cleft lip/palate

Root fragment

Fluorosis

Others, specify

TEMPORARY TEETH dtt index

Index: d. f. l. Pre-Schooler 1 2 3 4 5 6
No. T/ decayed
No. T/ filled
Total d.f.l.

PERMANENT TEETH DMFT index

Index: D. M. F. T. Pre-Schooler 1 2 3 4 5 6
No. T/ Decayed
 No. T/Missing
No. T/Filled
Total D. M. F. T.
Total Sound Teeth

SYMBOLS FOR ACCOMPLISHMENT

xtracted permanent tooth OP - Oral prophylaxis
xtracted temporary tooth ZOE - Zinc Oxide Eugenol filling
- Amalgam filling TF - Temporary filling
Synthetic filling R - Referred

Artificial Restoration
acket Crown
ay
 REPUBLIC OF THE PHIIPPINES
DEPARTMENT OF EDUCATION
HEALTH AND NUTRITION CENTER
SCHOOLS DIVISION OF NUEVA ECIJA

SCHOOL HEALTH EXAMINATION CARD

Elementary Pupils

Name: School:
Last First Middle

Date of Birth: Region:

Month Day Year

Birthplace: Division:
Parent/Guardian Telephone No.:
Address:

Pre - Elem Grade 1 Grade 2 Grade 3

F I F I F I F
Date of Examination
Temperature/BP
Heart Rate/Pulse Rate/Respiratory Rate
Height
Weight
Nutritional Status (NS)
Visual Acuity (Snellen's)
a. N Rt, b. N Lft, c. AbN Rt, d. AbN Lft
Hearing (Turning fork)
a. N Rt, b. N Lft, c. AbN Rt, d. AbN Lft
Skin/Scalp
Eyes/Ears/Nose
Mouth/Throat/Neck
Lungs/Heart
Adbomen/Genitalia
Spine/Extremities
Others, specify
Examined by

NS Skin/Scalp Eye/Ear/Nose Mouth/Neck/Throat Lungs/Heart Abdomen/

Genitalia
a. Severely a. Pediculosis a. Squinting a. Lip lesion a. Rales a. Mass
Wasted

b.Wasted b. Tinea Flava b. Pale conjunctiva b. Enlarged tonsils with/

w/o exudates b. Wheeze b. Hemorrhoids
 c. Inflamed pharynx with
c.Over weight c. Ringworm c. Ear discharge w/o exudates c. Murmur c. Tenderness
d. Impacted d. Enlarged Thyroid d. Genital
d.Obese d. Eczema d. Deformed chest
cerumen gland Discharge

e. Impetigo/boil e. Septal deviation e. Speech defect e. Distant heart sounds e. Hernia

f. Hematoma f. Nasal discharge f. Dental problem f. Irregular heart rate f. Others, specify

g. Bruises/ g. Cough g. Cleft lip, Cleft palate g. Others, specify

lacerations
h.Cervical lymph
h. Allergy h.Dirty Ear
adenopathy

i. Others, specify i. Others, specify i. Others, specify

Note:Use letter to record ailments and place X if not examined

 ES
ON
NTER
ECIJA

TION CARD

Grade 3 Grade 4 Grade 5 Grade 6

I F I F I F I

Abdomen/ Spine/Extremities Remarks/ Intervention

Genitalia

a. Mass a. Deformity of the Spine a. Needs Supervision

b. Hemorrhoids b. Bowlegs/ knock knees b. Needs close supervision

c. Tenderness c. Flat foot c. Needs Follow - up
d. Genital
d. Club foot d. Corrected
Discharge

e. Hernia e. Others, specify e. Treated

f. Others, specify f. Advised/ Counseled

g. Referred

h. Parents notified

i. Others, specify

LEGEND:
F: Findings
I: Intervention
E/N: Essentially Normal