Form No.3 Republic of the Philippines DEPARTMENT OF EDUCATION Region Division DENTAL HEALTH RECORD Date Name: Age: Sex Birth Date Event: arent/Guardian: Coach: GINGIVITIS 55 54 53 52 51 61 62 63 64 65 MALOCCLUSION 18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 DECUBITAL ULCER 48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CALCULUS CLEFT PALATE ROOT FRAGMENT FLUOROSIS 85 84 83 82 81 71 72 73 74 75 OTHERS (Specify) DATE OF VIS 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 TOOT FOR EXTRACTION MAL - MALOCLUSSION xt - EXTRACTED TEMPORARY TOOT F - TOOTH INDICATED FLU - FLOUROSIS Am - AMALGAM FILLING FOR FILLING Gn - NORMAL Com - COMPOSITE FILLING - TOOTH WITH TEMPORARY Gm - MODERATE GINGIVITIS 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 FILLI TOOTH TF - TEMPORARY FILLING R - REFERRED TO PRIVATE DENT REMARKS: UN - UNERUPTED DENTIST PRERIODICAL DISEASE SUPERNUMERAR Y TOOTH DECIDOUS TEETH HEAVY SHADE PERMANENT TEETH CONDITION TREATMENT NEEDS LEFT RIGHT CONDITION TEMPORARY TEETH TEMPORARY TEETH RIGHT CONDITION LEFT CONDITION AND TREATMENT NEEDS Latest 1½ x 1½ pict
