J.H. CERILLES STATE COLLEGE
ORAL HEALTH EXAMINATION RECORD FOR STUDENTS
| Name: | 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
| INDEX: DMFT | |
|---|---|
| No. of Tooth Decayed (D) | |
| No. of Tooth Missing (M) | |
| No. of Tooth Filled (F) | |
| Total | |
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
Treatment Record
| DATE | TOOTH NO. | NATURE OF OPERATION | REMARKS | DENTIST |
|---|---|---|---|---|