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J.H. CERILLES STATE COLLEGE

ORAL HEALTH EXAMINATION RECORD FOR STUDENTS

Age: Gender: Course/Year:
Date of Birth: Civil Status: Religion:
Address:
Parents/Guardian: CP No.:
Medical History:
Normal Epilepsy Allergies Diabetes
Bleeding Disorder Cardio Vascular Disorder Asthma Others:

DENTITION STATUS

Symbols for Mouth Examination
  • X - Indicated for extraction
  • F - Indicated for filling
  • RF - Root fragment
  • O - Missing tooth
Symbols for Accomplishment
  • OP - Oral Prophylaxis
  • X - Extracted permanent tooth
  • R - Referred to private dentist
  • ZnO F - Zinc Oxide Filling
  • GIC- Glass Ioner Cement
INDEX: DMFT
No. of Tooth Decayed (D)
No. of Tooth Missing (M)
No. of Tooth Filled (F)
Total
Date Tooth No. Operation Remarks Dentist Action
Date Tooth No. Operation Remarks Dentist

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