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    2020 Dental-Certificate

    Uploaded by

    Mia Bert Nunag Gabawa

    Copyright:

    © All Rights Reserved
    Download as XLS, PDF, TXT or read online from Scribd

    2020 Dental-Certificate

    Uploaded by

    Mia Bert Nunag Gabawa
    3 views2 pages

    Original Title

    2020_Dental-Certificate (1)

    Copyright

    © © All Rights Reserved

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    Copyright:

    © All Rights Reserved
    Download as XLS, PDF, TXT or read online from Scribd
    Download as xls, pdf, or txt
    3 views2 pages

    2020 Dental-Certificate

    Uploaded by

    Mia Bert Nunag Gabawa

    Copyright:

    © All Rights Reserved
    Download as XLS, PDF, TXT or read online from Scribd
    Download as xls, pdf, or txt
    of 2

    Revised as of September 26, 2019 Republic of the Philippines

    DEPARTMENT OF EDUCATION

    Region

    Division

    Latest 1½ x 1½ picture
    DENTAL HEALTH RECORD
    Name:
    Age: Sex: 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

    CONDITION

    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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