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    2020 - Dental Certificate

    Uploaded by

    criselle
    This document is a dental health record for a student named Cyrus C. Mascarinas. It contains information such as his name, age, sex, birthdate, parent/guardian, dental conditions and treatment needs for both temporary and permanent teeth, and examination details for school sports participation qualifications. The record will be used to document dental examinations and any necessary treatments or referrals for dental care over time.

    Copyright:

    © All Rights Reserved
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    2020 - Dental Certificate

    Uploaded by

    criselle
    5 views17 pages
    This document is a dental health record for a student named Cyrus C. Mascarinas. It contains information such as his name, age, sex, birthdate, parent/guardian, dental conditions and treatment needs for both temporary and permanent teeth, and examination details for school sports participation qualifications. The record will be used to document dental examinations and any necessary treatments or referrals for dental care over time.

    Original Description:

    Original Title

    2020_Dental Certificate

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    This document is a dental health record for a student named Cyrus C. Mascarinas. It contains information such as his name, age, sex, birthdate, parent/guardian, dental conditions and treatment needs for both temporary and permanent teeth, and examination details for school sports participation qualifications. The record will be used to document dental examinations and any necessary treatments or referrals for dental care over time.

    Copyright:

    © All Rights Reserved
    Download as XLSX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as xlsx, pdf, or txt
    5 views17 pages

    2020 - Dental Certificate

    Uploaded by

    criselle
    This document is a dental health record for a student named Cyrus C. Mascarinas. It contains information such as his name, age, sex, birthdate, parent/guardian, dental conditions and treatment needs for both temporary and permanent teeth, and examination details for school sports participation qualifications. The record will be used to document dental examinations and any necessary treatments or referrals for dental care over time.

    Copyright:

    © All Rights Reserved
    Download as XLSX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as xlsx, pdf, or txt
    of 17

    Revised as of September 26, 2019 Republic of the Philippines

    DEPARTMENT OF EDUCATION
    MIMAROPA
    Region
    ORIENTAL MINDORO
    Division

    DENTAL HEALTH RECORD Latest 1½ x 1½ picture

    Name:
    Age: Sex: MALE Birth Date:

    Event:
    Parent/Guardian:

    CONDITION AND TREATMENT NEEDS


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

    18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
    PERMANENT
    TEETH
    48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
    CONDITION

    TREATMENT NEEDS
    TEMPORARY TEETH
    RIGHT
    85 84 83 82 81 71 72 73 74 75 LEFT

    CONDITIO
    N

    YEAR LEVEL REMARKS


    DATE
    EXAMINATION
    SEALANT (GI)
    PERMANENT FILLING
    ART
    EXTRACTION
    ORAL PROPHYLAXIS
    REFERRAL
    OTHER ORAL
    TREATMENT

    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

    District Meet Remarks/Findings:


    WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT
    DENTIST YES NO YES NO
    (signature over printed name) QUALIFIED TO PARTICiPATE:
    PRC: LICENSE: PTR# Date Examined: YES NO
    Division Meet Remarks/Findings:
    WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT
    DENTIST YES NO YES NO
    (signature over printed name) QUALIFIED TO PARTICIPATE:
    PRC: LICENSE: PTR# Date Examined: YES NO
    Regional Meet Remarks/Findings:
    WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT
    DENTIST YES NO YES NO
    (signature over printed name) QUALIFIED TO PARTCIPATE:
    PRC: LICENSE: PTR# Date Examined: YES NO
    Palarong Pambansa Remarks/Findings:
    WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT
    DENTIST YES NO YES NO
    (signature over printed name) QUALIFIED TO PARTICIPATE:
    PRC: LICENSE: PTR# Date Examined: YES NO

    FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)


    Revised as of September 26, 2019 Republic of the Philippines
    DEPARTMENT OF EDUCATION
    MIMAROPA
    Region
    ORIENTAL MINDORO
    Division

    DENTAL HEALTH RECORD Latest 1½ x 1½ picture

    Name: CYRUS C. MASCARIÑAS

    Age: Sex: MALE Birth Date: 05/29/2011

    Event: CHESS

    Parent/Guardian: ROSARITA MASCARIÑAS

    CONDITION AND TREATMENT NEEDS


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

    18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
    PERMANENT
    TEETH
    48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
    CONDITION

    TREATMENT NEEDS
    TEMPORARY TEETH
    RIGHT
    85 84 83 82 81 71 72 73 74 75 LEFT

    CONDITIO
    N

    YEAR LEVEL REMARKS


    DATE
    EXAMINATION
    SEALANT (GI)
    PERMANENT FILLING
    ART
    EXTRACTION
    ORAL PROPHYLAXIS
    REFERRAL
    OTHER ORAL
    TREATMENT

    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

    District Meet Remarks/Findings:


    WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT
    DENTIST YES NO YES NO
    (signature over printed name) QUALIFIED TO PARTICiPATE:
    PRC: LICENSE: PTR# Date Examined: YES NO
    Division Meet Remarks/Findings:
    WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT
    DENTIST YES NO YES NO
    (signature over printed name) QUALIFIED TO PARTICIPATE:
    PRC: LICENSE: PTR# Date Examined: YES NO
    Regional Meet Remarks/Findings:
    WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT
    DENTIST YES NO YES NO
    (signature over printed name) QUALIFIED TO PARTCIPATE:
    PRC: LICENSE: PTR# Date Examined: YES NO
    Palarong Pambansa Remarks/Findings:
    WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT
    DENTIST YES NO YES NO
    (signature over printed name) QUALIFIED TO PARTICIPATE:
    PRC: LICENSE: PTR# Date Examined: YES NO

    FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)


    Revised as of September 26, 2019 Republic of the Philippines
    DEPARTMENT OF EDUCATION
    MIMAROPA
    Region
    ORIENTAL MINDORO
    Division

    DENTAL HEALTH RECORD Latest 1½ x 1½ picture

    Name: SHAN L. MANONGOL

    Age: Sex: FEMALE Birth Date: 2/1/2011

    Event: SOFTBALL-ELEMENTARY

    Parent/Guardian: CONCEPCION G. LOLONG

    CONDITION AND TREATMENT NEEDS


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

    18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
    PERMANENT
    TEETH
    48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
    CONDITION

    TREATMENT NEEDS
    TEMPORARY TEETH
    RIGHT
    85 84 83 82 81 71 72 73 74 75 LEFT

    CONDITIO
    N

    YEAR LEVEL REMARKS


    DATE
    EXAMINATION
    SEALANT (GI)
    PERMANENT FILLING
    ART
    EXTRACTION
    ORAL PROPHYLAXIS
    REFERRAL
    OTHER ORAL
    TREATMENT

    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

    District Meet Remarks/Findings:


    WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT
    DENTIST YES NO YES NO
    (signature over printed name) QUALIFIED TO PARTICiPATE:
    PRC: LICENSE: PTR# Date Examined: YES NO
    Division Meet Remarks/Findings:
    WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT
    DENTIST YES NO YES NO
    (signature over printed name) QUALIFIED TO PARTICIPATE:
    PRC: LICENSE: PTR# Date Examined: YES NO
    Regional Meet Remarks/Findings:
    WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT
    DENTIST YES NO YES NO
    (signature over printed name) QUALIFIED TO PARTCIPATE:
    PRC: LICENSE: PTR# Date Examined: YES NO
    Palarong Pambansa Remarks/Findings:
    WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT
    DENTIST YES NO YES NO
    (signature over printed name) QUALIFIED TO PARTICIPATE:
    PRC: LICENSE: PTR# Date Examined: YES NO

    FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)


    Revised as of September 26, 2019 Republic of the Philippines
    DEPARTMENT OF EDUCATION
    MIMAROPA
    Region
    ORIENTAL MINDORO
    Division

    DENTAL HEALTH RECORD Latest 1½ x 1½ picture

    Name: TRICIA HEART M. FRADEJAS

    Age: Sex: FEMALE Birth Date: 02/17/2012

    Event: SOFTBALL-ELEMENTARY

    Parent/Guardian: MARINA M. MAGARARU

    CONDITION AND TREATMENT NEEDS


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

    18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
    PERMANENT
    TEETH
    48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
    CONDITION

    TREATMENT NEEDS
    TEMPORARY TEETH
    RIGHT
    85 84 83 82 81 71 72 73 74 75 LEFT

    CONDITIO
    N

    YEAR LEVEL REMARKS


    DATE
    EXAMINATION
    SEALANT (GI)
    PERMANENT FILLING
    ART
    EXTRACTION
    ORAL PROPHYLAXIS
    REFERRAL
    OTHER ORAL
    TREATMENT

    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

    District Meet Remarks/Findings:


    WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT
    DENTIST YES NO YES NO
    (signature over printed name) QUALIFIED TO PARTICiPATE:
    PRC: LICENSE: PTR# Date Examined: YES NO
    Division Meet Remarks/Findings:
    WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT
    DENTIST YES NO YES NO
    (signature over printed name) QUALIFIED TO PARTICIPATE:
    PRC: LICENSE: PTR# Date Examined: YES NO
    Regional Meet Remarks/Findings:
    WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT
    DENTIST YES NO YES NO
    (signature over printed name) QUALIFIED TO PARTCIPATE:
    PRC: LICENSE: PTR# Date Examined: YES NO
    Palarong Pambansa Remarks/Findings:
    WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT
    DENTIST YES NO YES NO
    (signature over printed name) QUALIFIED TO PARTICIPATE:
    PRC: LICENSE: PTR# Date Examined: YES NO

    FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)


    Revised as of September 26, 2019 Republic of the Philippines
    DEPARTMENT OF EDUCATION
    MIMAROPA
    Region
    ORIENTAL MINDORO
    Division

    DENTAL HEALTH RECORD Latest 1½ x 1½ picture

    Name: PRINCESS AYEZA F. ESCUTO

    Age: Sex: FEMALE Birth Date: 9/3/2012

    Event: SOFTBALL-ELEMENTARY

    Parent/Guardian: MARIETA F. FADRIGON

    CONDITION AND TREATMENT NEEDS


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

    18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
    PERMANENT
    TEETH
    48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
    CONDITION

    TREATMENT NEEDS
    TEMPORARY TEETH
    RIGHT
    85 84 83 82 81 71 72 73 74 75 LEFT

    CONDITIO
    N

    YEAR LEVEL REMARKS


    DATE
    EXAMINATION
    SEALANT (GI)
    PERMANENT FILLING
    ART
    EXTRACTION
    ORAL PROPHYLAXIS
    REFERRAL
    OTHER ORAL
    TREATMENT

    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

    District Meet Remarks/Findings:


    WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT
    DENTIST YES NO YES NO
    (signature over printed name) QUALIFIED TO PARTICiPATE:
    PRC: LICENSE: PTR# Date Examined: YES NO
    Division Meet Remarks/Findings:
    WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT
    DENTIST YES NO YES NO
    (signature over printed name) QUALIFIED TO PARTICIPATE:
    PRC: LICENSE: PTR# Date Examined: YES NO
    Regional Meet Remarks/Findings:
    WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT
    DENTIST YES NO YES NO
    (signature over printed name) QUALIFIED TO PARTCIPATE:
    PRC: LICENSE: PTR# Date Examined: YES NO
    Palarong Pambansa Remarks/Findings:
    WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT
    DENTIST YES NO YES NO
    (signature over printed name) QUALIFIED TO PARTICIPATE:
    PRC: LICENSE: PTR# Date Examined: YES NO

    FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)


    Revised as of September 26, 2019 Republic of the Philippines
    DEPARTMENT OF EDUCATION
    MIMAROPA
    Region
    ORIENTAL MINDORO
    Division

    DENTAL HEALTH RECORD Latest 1½ x 1½ picture

    Name: ANGEL L. MALLOPA

    Age: Sex: FEMALE Birth Date: 3/8/2013

    Event: SOFTBALL-ELEMENTARY

    Parent/Guardian: GLENDA L. LARIRIT

    CONDITION AND TREATMENT NEEDS


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

    18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
    PERMANENT
    TEETH
    48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
    CONDITION

    TREATMENT NEEDS
    TEMPORARY TEETH
    RIGHT
    85 84 83 82 81 71 72 73 74 75 LEFT

    CONDITIO
    N

    YEAR LEVEL REMARKS


    DATE
    EXAMINATION
    SEALANT (GI)
    PERMANENT FILLING
    ART
    EXTRACTION
    ORAL PROPHYLAXIS
    REFERRAL
    OTHER ORAL
    TREATMENT

    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

    District Meet Remarks/Findings:


    WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT
    DENTIST YES NO YES NO
    (signature over printed name) QUALIFIED TO PARTICiPATE:
    PRC: LICENSE: PTR# Date Examined: YES NO
    Division Meet Remarks/Findings:
    WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT
    DENTIST YES NO YES NO
    (signature over printed name) QUALIFIED TO PARTICIPATE:
    PRC: LICENSE: PTR# Date Examined: YES NO
    Regional Meet Remarks/Findings:
    WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT
    DENTIST YES NO YES NO
    (signature over printed name) QUALIFIED TO PARTCIPATE:
    PRC: LICENSE: PTR# Date Examined: YES NO
    Palarong Pambansa Remarks/Findings:
    WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT
    DENTIST YES NO YES NO
    (signature over printed name) QUALIFIED TO PARTICIPATE:
    PRC: LICENSE: PTR# Date Examined: YES NO

    FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)


    Revised as of September 26, 2019 Republic of the Philippines
    DEPARTMENT OF EDUCATION
    MIMAROPA
    Region
    ORIENTAL MINDORO
    Division

    DENTAL HEALTH RECORD Latest 1½ x 1½ picture

    Name: JHANNIS D. ENGRACIA

    Age: Sex: FEMALE Birth Date: 03/24/2013

    Event: SOFTBALL-ELEMENTARY

    Parent/Guardian: ROVINA S. DELOS SANTOS

    CONDITION AND TREATMENT NEEDS


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

    18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
    PERMANENT
    TEETH
    48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
    CONDITION

    TREATMENT NEEDS
    TEMPORARY TEETH
    RIGHT
    85 84 83 82 81 71 72 73 74 75 LEFT

    CONDITIO
    N

    YEAR LEVEL REMARKS


    DATE
    EXAMINATION
    SEALANT (GI)
    PERMANENT FILLING
    ART
    EXTRACTION
    ORAL PROPHYLAXIS
    REFERRAL
    OTHER ORAL
    TREATMENT

    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

    District Meet Remarks/Findings:


    WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT
    DENTIST YES NO YES NO
    (signature over printed name) QUALIFIED TO PARTICiPATE:
    PRC: LICENSE: PTR# Date Examined: YES NO
    Division Meet Remarks/Findings:
    WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT
    DENTIST YES NO YES NO
    (signature over printed name) QUALIFIED TO PARTICIPATE:
    PRC: LICENSE: PTR# Date Examined: YES NO
    Regional Meet Remarks/Findings:
    WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT
    DENTIST YES NO YES NO
    (signature over printed name) QUALIFIED TO PARTCIPATE:
    PRC: LICENSE: PTR# Date Examined: YES NO
    Palarong Pambansa Remarks/Findings:
    WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT
    DENTIST YES NO YES NO
    (signature over printed name) QUALIFIED TO PARTICIPATE:
    PRC: LICENSE: PTR# Date Examined: YES NO

    FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)


    Revised as of September 26, 2019 Republic of the Philippines
    DEPARTMENT OF EDUCATION
    MIMAROPA
    Region
    ORIENTAL MINDORO
    Division

    DENTAL HEALTH RECORD Latest 1½ x 1½ picture

    Name: KHEAN S. MALLARI

    Age: Sex: FEMALE Birth Date: 08/18/2011

    Event: SOFTBALL-ELEMENTARY

    Parent/Guardian: BABY WINCY M. SEMILLA

    CONDITION AND TREATMENT NEEDS


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

    18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
    PERMANENT
    TEETH
    48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
    CONDITION

    TREATMENT NEEDS
    TEMPORARY TEETH
    RIGHT
    85 84 83 82 81 71 72 73 74 75 LEFT

    CONDITIO
    N

    YEAR LEVEL REMARKS


    DATE
    EXAMINATION
    SEALANT (GI)
    PERMANENT FILLING
    ART
    EXTRACTION
    ORAL PROPHYLAXIS
    REFERRAL
    OTHER ORAL
    TREATMENT

    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

    District Meet Remarks/Findings:


    WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT
    DENTIST YES NO YES NO
    (signature over printed name) QUALIFIED TO PARTICiPATE:
    PRC: LICENSE: PTR# Date Examined: YES NO
    Division Meet Remarks/Findings:
    WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT
    DENTIST YES NO YES NO
    (signature over printed name) QUALIFIED TO PARTICIPATE:
    PRC: LICENSE: PTR# Date Examined: YES NO
    Regional Meet Remarks/Findings:
    WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT
    DENTIST YES NO YES NO
    (signature over printed name) QUALIFIED TO PARTCIPATE:
    PRC: LICENSE: PTR# Date Examined: YES NO
    Palarong Pambansa Remarks/Findings:
    WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT
    DENTIST YES NO YES NO
    (signature over printed name) QUALIFIED TO PARTICIPATE:
    PRC: LICENSE: PTR# Date Examined: YES NO

    FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)


    Revised as of September 26, 2019 Republic of the Philippines
    DEPARTMENT OF EDUCATION
    MIMAROPA
    Region
    ORIENTAL MINDORO
    Division

    DENTAL HEALTH RECORD Latest 1½ x 1½ picture

    Name: AILA MAY B. LACEDA

    Age: Sex: FEMALE Birth Date: 05/13/2011

    Event: SOFTBALL-ELEMENTARY

    Parent/Guardian: MARICEL A. BRAVIO

    CONDITION AND TREATMENT NEEDS


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

    18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
    PERMANENT
    TEETH
    48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
    CONDITION

    TREATMENT NEEDS
    TEMPORARY TEETH
    RIGHT
    85 84 83 82 81 71 72 73 74 75 LEFT

    CONDITIO
    N

    YEAR LEVEL REMARKS


    DATE
    EXAMINATION
    SEALANT (GI)
    PERMANENT FILLING
    ART
    EXTRACTION
    ORAL PROPHYLAXIS
    REFERRAL
    OTHER ORAL
    TREATMENT

    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

    District Meet Remarks/Findings:


    WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT
    DENTIST YES NO YES NO
    (signature over printed name) QUALIFIED TO PARTICiPATE:
    PRC: LICENSE: PTR# Date Examined: YES NO
    Division Meet Remarks/Findings:
    WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT
    DENTIST YES NO YES NO
    (signature over printed name) QUALIFIED TO PARTICIPATE:
    PRC: LICENSE: PTR# Date Examined: YES NO
    Regional Meet Remarks/Findings:
    WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT
    DENTIST YES NO YES NO
    (signature over printed name) QUALIFIED TO PARTCIPATE:
    PRC: LICENSE: PTR# Date Examined: YES NO
    Palarong Pambansa Remarks/Findings:
    WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT
    DENTIST YES NO YES NO
    (signature over printed name) QUALIFIED TO PARTICIPATE:
    PRC: LICENSE: PTR# Date Examined: YES NO

    FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)


    Revised as of September 26, 2019 Republic of the Philippines
    DEPARTMENT OF EDUCATION
    MIMAROPA
    Region
    ORIENTAL MINDORO
    Division

    DENTAL HEALTH RECORD Latest 1½ x 1½ picture

    Name: ERLYN H. OLIVAR

    Age: Sex: FEMALE Birth Date: 12/6/2012

    Event: SOFTBALL-ELEMENTARY

    Parent/Guardian: MARICEL P. HERNANDEZ

    CONDITION AND TREATMENT NEEDS


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

    18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
    PERMANENT
    TEETH
    48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
    CONDITION

    TREATMENT NEEDS
    TEMPORARY TEETH
    RIGHT
    85 84 83 82 81 71 72 73 74 75 LEFT

    CONDITIO
    N

    YEAR LEVEL REMARKS


    DATE
    EXAMINATION
    SEALANT (GI)
    PERMANENT FILLING
    ART
    EXTRACTION
    ORAL PROPHYLAXIS
    REFERRAL
    OTHER ORAL
    TREATMENT

    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

    District Meet Remarks/Findings:


    WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT
    DENTIST YES NO YES NO
    (signature over printed name) QUALIFIED TO PARTICiPATE:
    PRC: LICENSE: PTR# Date Examined: YES NO
    Division Meet Remarks/Findings:
    WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT
    DENTIST YES NO YES NO
    (signature over printed name) QUALIFIED TO PARTICIPATE:
    PRC: LICENSE: PTR# Date Examined: YES NO
    Regional Meet Remarks/Findings:
    WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT
    DENTIST YES NO YES NO
    (signature over printed name) QUALIFIED TO PARTCIPATE:
    PRC: LICENSE: PTR# Date Examined: YES NO
    Palarong Pambansa Remarks/Findings:
    WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT
    DENTIST YES NO YES NO
    (signature over printed name) QUALIFIED TO PARTICIPATE:
    PRC: LICENSE: PTR# Date Examined: YES NO

    FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)


    Revised as of September 26, 2019 Republic of the Philippines
    DEPARTMENT OF EDUCATION
    MIMAROPA
    Region
    ORIENTAL MINDORO
    Division

    DENTAL HEALTH RECORD Latest 1½ x 1½ picture

    Name: SHAMEL S. MONTON

    Age: Sex: FEMALE Birth Date: 7/9/2011

    Event: SOFTBALL-ELEMENTARY

    Parent/Guardian: ANGELINA L. SELDA

    CONDITION AND TREATMENT NEEDS


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

    18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
    PERMANENT
    TEETH
    48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
    CONDITION

    TREATMENT NEEDS
    TEMPORARY TEETH
    RIGHT
    85 84 83 82 81 71 72 73 74 75 LEFT

    CONDITIO
    N

    YEAR LEVEL REMARKS


    DATE
    EXAMINATION
    SEALANT (GI)
    PERMANENT FILLING
    ART
    EXTRACTION
    ORAL PROPHYLAXIS
    REFERRAL
    OTHER ORAL
    TREATMENT

    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

    District Meet Remarks/Findings:


    WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT
    DENTIST YES NO YES NO
    (signature over printed name) QUALIFIED TO PARTICiPATE:
    PRC: LICENSE: PTR# Date Examined: YES NO
    Division Meet Remarks/Findings:
    WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT
    DENTIST YES NO YES NO
    (signature over printed name) QUALIFIED TO PARTICIPATE:
    PRC: LICENSE: PTR# Date Examined: YES NO
    Regional Meet Remarks/Findings:
    WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT
    DENTIST YES NO YES NO
    (signature over printed name) QUALIFIED TO PARTCIPATE:
    PRC: LICENSE: PTR# Date Examined: YES NO
    Palarong Pambansa Remarks/Findings:
    WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT
    DENTIST YES NO YES NO
    (signature over printed name) QUALIFIED TO PARTICIPATE:
    PRC: LICENSE: PTR# Date Examined: YES NO

    FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)


    Revised as of September 26, 2019 Republic of the Philippines
    DEPARTMENT OF EDUCATION
    MIMAROPA
    Region
    ORIENTAL MINDORO
    Division

    DENTAL HEALTH RECORD Latest 1½ x 1½ picture

    Name: MAEREL JANE A. FABRERO

    Age: Sex: FEMALE Birth Date: 02/15/2011

    Event: SOFTBALL-ELEMENTARY

    Parent/Guardian: MAILA L. AGARIN

    CONDITION AND TREATMENT NEEDS


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

    18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
    PERMANENT
    TEETH
    48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
    CONDITION

    TREATMENT NEEDS
    TEMPORARY TEETH
    RIGHT
    85 84 83 82 81 71 72 73 74 75 LEFT

    CONDITIO
    N

    YEAR LEVEL REMARKS


    DATE
    EXAMINATION
    SEALANT (GI)
    PERMANENT FILLING
    ART
    EXTRACTION
    ORAL PROPHYLAXIS
    REFERRAL
    OTHER ORAL
    TREATMENT

    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

    District Meet Remarks/Findings:


    WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT
    DENTIST YES NO YES NO
    (signature over printed name) QUALIFIED TO PARTICiPATE:
    PRC: LICENSE: PTR# Date Examined: YES NO
    Division Meet Remarks/Findings:
    WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT
    DENTIST YES NO YES NO
    (signature over printed name) QUALIFIED TO PARTICIPATE:
    PRC: LICENSE: PTR# Date Examined: YES NO
    Regional Meet Remarks/Findings:
    WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT
    DENTIST YES NO YES NO
    (signature over printed name) QUALIFIED TO PARTCIPATE:
    PRC: LICENSE: PTR# Date Examined: YES NO
    Palarong Pambansa Remarks/Findings:
    WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT
    DENTIST YES NO YES NO
    (signature over printed name) QUALIFIED TO PARTICIPATE:
    PRC: LICENSE: PTR# Date Examined: YES NO

    FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)


    Revised as of September 26, 2019 Republic of the Philippines
    DEPARTMENT OF EDUCATION
    MIMAROPA
    Region
    ORIENTAL MINDORO
    Division

    DENTAL HEALTH RECORD Latest 1½ x 1½ picture

    Name: JHAMICA S. ILAO

    Age: Sex: FEMALE Birth Date: 2/1/2011

    Event: SOFTBALL-ELEMENTARY

    Parent/Guardian: ANALYN L. SADIWA

    CONDITION AND TREATMENT NEEDS


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

    18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
    PERMANENT
    TEETH
    48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
    CONDITION

    TREATMENT NEEDS
    TEMPORARY TEETH
    RIGHT
    85 84 83 82 81 71 72 73 74 75 LEFT

    CONDITIO
    N

    YEAR LEVEL REMARKS


    DATE
    EXAMINATION
    SEALANT (GI)
    PERMANENT FILLING
    ART
    EXTRACTION
    ORAL PROPHYLAXIS
    REFERRAL
    OTHER ORAL
    TREATMENT

    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

    District Meet Remarks/Findings:


    WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT
    DENTIST YES NO YES NO
    (signature over printed name) QUALIFIED TO PARTICiPATE:
    PRC: LICENSE: PTR# Date Examined: YES NO
    Division Meet Remarks/Findings:
    WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT
    DENTIST YES NO YES NO
    (signature over printed name) QUALIFIED TO PARTICIPATE:
    PRC: LICENSE: PTR# Date Examined: YES NO
    Regional Meet Remarks/Findings:
    WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT
    DENTIST YES NO YES NO
    (signature over printed name) QUALIFIED TO PARTCIPATE:
    PRC: LICENSE: PTR# Date Examined: YES NO
    Palarong Pambansa Remarks/Findings:
    WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT
    DENTIST YES NO YES NO
    (signature over printed name) QUALIFIED TO PARTICIPATE:
    PRC: LICENSE: PTR# Date Examined: YES NO

    FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)


    Revised as of September 26, 2019 Republic of the Philippines
    DEPARTMENT OF EDUCATION
    MIMAROPA
    Region
    ORIENTAL MINDORO
    Division

    DENTAL HEALTH RECORD Latest 1½ x 1½ picture

    Name: ASHLEY L. MONTON

    Age: Sex: FEMALE Birth Date: 9/5/2012

    Event: SOFTBALL-ELEMENTARY

    Parent/Guardian: MELIZA L. MONTON

    CONDITION AND TREATMENT NEEDS


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

    18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
    PERMANENT
    TEETH
    48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
    CONDITION

    TREATMENT NEEDS
    TEMPORARY TEETH
    RIGHT
    85 84 83 82 81 71 72 73 74 75 LEFT

    CONDITIO
    N

    YEAR LEVEL REMARKS


    DATE
    EXAMINATION
    SEALANT (GI)
    PERMANENT FILLING
    ART
    EXTRACTION
    ORAL PROPHYLAXIS
    REFERRAL
    OTHER ORAL
    TREATMENT

    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

    District Meet Remarks/Findings:


    WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT
    DENTIST YES NO YES NO
    (signature over printed name) QUALIFIED TO PARTICiPATE:
    PRC: LICENSE: PTR# Date Examined: YES NO
    Division Meet Remarks/Findings:
    WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT
    DENTIST YES NO YES NO
    (signature over printed name) QUALIFIED TO PARTICIPATE:
    PRC: LICENSE: PTR# Date Examined: YES NO
    Regional Meet Remarks/Findings:
    WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT
    DENTIST YES NO YES NO
    (signature over printed name) QUALIFIED TO PARTCIPATE:
    PRC: LICENSE: PTR# Date Examined: YES NO
    Palarong Pambansa Remarks/Findings:
    WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT
    DENTIST YES NO YES NO
    (signature over printed name) QUALIFIED TO PARTICIPATE:
    PRC: LICENSE: PTR# Date Examined: YES NO

    FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)


    Revised as of September 26, 2019 Republic of the Philippines
    DEPARTMENT OF EDUCATION
    MIMAROPA
    Region
    ORIENTAL MINDORO
    Division

    DENTAL HEALTH RECORD Latest 1½ x 1½ picture

    Name: AILA MAY B. LACEDA

    Age: Sex: FEMALE Birth Date: 05/13/2011

    Event: SOFTBALL-ELEMENTARY

    Parent/Guardian: MARICEL A. BRAVIO

    CONDITION AND TREATMENT NEEDS


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

    18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
    PERMANENT
    TEETH
    48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
    CONDITION

    TREATMENT NEEDS
    TEMPORARY TEETH
    RIGHT
    85 84 83 82 81 71 72 73 74 75 LEFT

    CONDITIO
    N

    YEAR LEVEL REMARKS


    DATE
    EXAMINATION
    SEALANT (GI)
    PERMANENT FILLING
    ART
    EXTRACTION
    ORAL PROPHYLAXIS
    REFERRAL
    OTHER ORAL
    TREATMENT

    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

    District Meet Remarks/Findings:


    WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT
    DENTIST YES NO YES NO
    (signature over printed name) QUALIFIED TO PARTICiPATE:
    PRC: LICENSE: PTR# Date Examined: YES NO
    Division Meet Remarks/Findings:
    WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT
    DENTIST YES NO YES NO
    (signature over printed name) QUALIFIED TO PARTICIPATE:
    PRC: LICENSE: PTR# Date Examined: YES NO
    Regional Meet Remarks/Findings:
    WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT
    DENTIST YES NO YES NO
    (signature over printed name) QUALIFIED TO PARTCIPATE:
    PRC: LICENSE: PTR# Date Examined: YES NO
    Palarong Pambansa Remarks/Findings:
    WITH THIRD MOLAR: REFERRED FOR DENTAL TREATMENT
    DENTIST YES NO YES NO
    (signature over printed name) QUALIFIED TO PARTICIPATE:
    PRC: LICENSE: PTR# Date Examined: YES NO

    FOR SCHOOL SPORTS (Lower Meet up to Palarong Pambansa)

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