Dental Certificate 2010 Palaro 1
Dental Certificate 2010 Palaro 1
Dental Certificate 2010 Palaro 1
003 DC
DEPARTMENT OF EDUCATION
4A
Region
CAVITE CITY
Division
Name:
Age:
Latest
PAOLO H. MONTIEL
14
Sex
Event:
Birth Date
19-Feb-01
FOOTBALL
Parent/Guardian:
CARLO P MONTIEL
Coach:
NENETH P. MANRIQUE
GINGIVITIS
PRERIODICAL
DISEASE
MALOCCLUSION
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
CLEFT PALATE
TREATMENT NEEDS
ROOT FRAGMENT
FLUOROSIS
OTHERS (Specify)
TEMPORARY TEETH
RIGHT
85 84 83 82 81 71 72 73 74 75
SUPERNUME
RARY
TOOTH
RETAINED
DECIDOUS
TEETH
DECUBITAL ULCER
CALCULUS
LEFT
CONDITION
YEAR LEVEL
DATE
EXAMINATION
SEALANT (GI)
PERMANENT FILLING
ART
EXTRACTION
ORAL PROPHYLAXIS
REFERRAL
OTHER ORAL TREATMEN
REMARKS
TEMPORARY TEETH
INDEX D.F.T.
NO. T /DECAYED
NO. T/ FILLED
TOTAL D.F.T.
TEMPORARY TEETH
INDEX D.F.T.
NO. T /DECAYED
NO. T/MISSING
NO. T/ FILLED
TOTAL D.F.T.
TOTAL SOUND TEETH
FOR FILLING
TOOTH
WITH TEMPORARY
HEAVY
SHADE
FILLING
RC - RECURRENT CARIES
RF - ROOT FRAGMENT
M - MISSING TOOTH
REMARKS:
Gn Gm Gs CMR () -
NORMAL
MODERATE GINGIVITIS
(1-2 QUADRANTS)
SEVERE GINGIVITIS
(3-4 QUADRANTS)
COMPLETE MOUTH REHAB
SOUND ERUPTED PERMANENT
TOOTH
Com
COMPOSITE F
JC
I
OP
ZOE
TF
R
UN
ARTIFICIAL REST
- JACKET CROW
- INLAY
- ORAL PROPHY
- ZINC OXIDE U
- TEMPORARY F
- REFERRED TO
- UNERUPTED
DENTIST
(signature over printe
PRC: LICENSE;
Latest 1 x 1 picture
DATE OF VISIT
R ACCOMPLISHMENT
ACTED PERMANENT TOOTH
ACTED TEMPORARY TOOTH
GAM FILLING
OSITE FILLING
AL RESTORATION
T CROWN
PROPHYLAXIS
OXIDE UEGENOL FILLING
ORARY FILLING
RRED TO PRIVATE DENTIST
UPTED
NTIST
er printed name)
DEPARTMENT OF EDUCATION
4A
Region
CAVITE CITY
Division
Name:
Latest
Age:
14
Event:
Sex
Birth Date
FOOTBALL
Parent/Guardian:
Coach:
NENETH P. MANRIQUE
GINGIVITIS
PRERIODICAL
DISEASE
MALOCCLUSION
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
CLEFT PALATE
TREATMENT NEEDS
ROOT FRAGMENT
FLUOROSIS
OTHERS (Specify)
TEMPORARY TEETH
RIGHT
85 84 83 82 81 71 72 73 74 75
SUPERNUME
RARY
TOOTH
RETAINED
DECIDOUS
TEETH
DECUBITAL ULCER
CALCULUS
LEFT
CONDITION
YEAR LEVEL
DATE
EXAMINATION
SEALANT (GI)
PERMANENT FILLING
ART
EXTRACTION
ORAL PROPHYLAXIS
REFERRAL
OTHER ORAL TREATMEN
REMARKS
TEMPORARY TEETH
INDEX D.F.T.
NO. T /DECAYED
NO. T/ FILLED
TOTAL D.F.T.
TEMPORARY TEETH
INDEX D.F.T.
NO. T /DECAYED
NO. T/MISSING
NO. T/ FILLED
TOTAL D.F.T.
TOTAL SOUND TEETH
FOR FILLING
TOOTH
WITH TEMPORARY
HEAVY
SHADE
FILLING
RC - RECURRENT CARIES
RF - ROOT FRAGMENT
M - MISSING TOOTH
REMARKS:
Gn Gm Gs CMR () -
NORMAL
MODERATE GINGIVITIS
(1-2 QUADRANTS)
SEVERE GINGIVITIS
(3-4 QUADRANTS)
COMPLETE MOUTH REHAB
SOUND ERUPTED PERMANENT
TOOTH
Com
COMPOSITE F
JC
I
OP
ZOE
TF
R
UN
ARTIFICIAL REST
- JACKET CROW
- INLAY
- ORAL PROPHY
- ZINC OXIDE U
- TEMPORARY F
- REFERRED TO
- UNERUPTED
DENTIST
(signature over printe
PRC: LICENSE;
Latest 1 x 1 picture
DATE OF VISIT
R ACCOMPLISHMENT
ACTED PERMANENT TOOTH
ACTED TEMPORARY TOOTH
GAM FILLING
OSITE FILLING
AL RESTORATION
T CROWN
PROPHYLAXIS
OXIDE UEGENOL FILLING
ORARY FILLING
RRED TO PRIVATE DENTIST
UPTED
NTIST
er printed name)
DEPARTMENT OF EDUCATION
4A
Region
CAVITE CITY
Division
Name:
Age:
Latest
Sex
Event:
Birth Date
OCT. 6, 2001
FOOTBALL
Parent/Guardian:
Coach:
NENETH P. MANRIQUE
GINGIVITIS
PRERIODICAL
DISEASE
MALOCCLUSION
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
CLEFT PALATE
TREATMENT NEEDS
ROOT FRAGMENT
FLUOROSIS
OTHERS (Specify)
TEMPORARY TEETH
RIGHT
85 84 83 82 81 71 72 73 74 75
SUPERNUME
RARY
TOOTH
RETAINED
DECIDOUS
TEETH
DECUBITAL ULCER
CALCULUS
LEFT
CONDITION
YEAR LEVEL
DATE
EXAMINATION
SEALANT (GI)
PERMANENT FILLING
ART
EXTRACTION
ORAL PROPHYLAXIS
REFERRAL
OTHER ORAL TREATMEN
REMARKS
TEMPORARY TEETH
INDEX D.F.T.
NO. T /DECAYED
NO. T/ FILLED
TOTAL D.F.T.
TEMPORARY TEETH
INDEX D.F.T.
NO. T /DECAYED
NO. T/MISSING
NO. T/ FILLED
TOTAL D.F.T.
TOTAL SOUND TEETH
FOR FILLING
TOOTH
WITH TEMPORARY
HEAVY
SHADE
FILLING
RC - RECURRENT CARIES
RF - ROOT FRAGMENT
M - MISSING TOOTH
REMARKS:
Gn Gm Gs CMR () -
NORMAL
MODERATE GINGIVITIS
(1-2 QUADRANTS)
SEVERE GINGIVITIS
(3-4 QUADRANTS)
COMPLETE MOUTH REHAB
SOUND ERUPTED PERMANENT
TOOTH
Com
COMPOSITE F
JC
I
OP
ZOE
TF
R
UN
ARTIFICIAL REST
- JACKET CROW
- INLAY
- ORAL PROPHY
- ZINC OXIDE U
- TEMPORARY F
- REFERRED TO
- UNERUPTED
DENTIST
(signature over printe
PRC: LICENSE;
Latest 1 x 1 picture
DATE OF VISIT
R ACCOMPLISHMENT
ACTED PERMANENT TOOTH
ACTED TEMPORARY TOOTH
GAM FILLING
OSITE FILLING
AL RESTORATION
T CROWN
PROPHYLAXIS
OXIDE UEGENOL FILLING
ORARY FILLING
RRED TO PRIVATE DENTIST
UPTED
NTIST
er printed name)
DEPARTMENT OF EDUCATION
4A
Region
CAVITE CITY
Division
Age:
Latest
Name:
14
Sex
Event:
Birth Date
FOOTBALL
Parent/Guardian:
Coach:
NENETH P. MANRIQUE
GINGIVITIS
PRERIODICAL
DISEASE
MALOCCLUSION
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
CLEFT PALATE
TREATMENT NEEDS
ROOT FRAGMENT
FLUOROSIS
OTHERS (Specify)
TEMPORARY TEETH
RIGHT
85 84 83 82 81 71 72 73 74 75
SUPERNUME
RARY
TOOTH
RETAINED
DECIDOUS
TEETH
DECUBITAL ULCER
CALCULUS
LEFT
CONDITION
YEAR LEVEL
DATE
EXAMINATION
SEALANT (GI)
PERMANENT FILLING
ART
EXTRACTION
ORAL PROPHYLAXIS
REFERRAL
OTHER ORAL TREATMEN
REMARKS
TEMPORARY TEETH
INDEX D.F.T.
NO. T /DECAYED
NO. T/ FILLED
TOTAL D.F.T.
TEMPORARY TEETH
INDEX D.F.T.
NO. T /DECAYED
NO. T/MISSING
NO. T/ FILLED
TOTAL D.F.T.
TOTAL SOUND TEETH
FOR FILLING
TOOTH
WITH TEMPORARY
HEAVY
SHADE
FILLING
RC - RECURRENT CARIES
RF - ROOT FRAGMENT
M - MISSING TOOTH
REMARKS:
Gn Gm Gs CMR () -
NORMAL
MODERATE GINGIVITIS
(1-2 QUADRANTS)
SEVERE GINGIVITIS
(3-4 QUADRANTS)
COMPLETE MOUTH REHAB
SOUND ERUPTED PERMANENT
TOOTH
Com
COMPOSITE F
JC
I
OP
ZOE
TF
R
UN
ARTIFICIAL REST
- JACKET CROW
- INLAY
- ORAL PROPHY
- ZINC OXIDE U
- TEMPORARY F
- REFERRED TO
- UNERUPTED
DENTIST
(signature over printe
PRC: LICENSE;
Latest 1 x 1 picture
DATE OF VISIT
R ACCOMPLISHMENT
ACTED PERMANENT TOOTH
ACTED TEMPORARY TOOTH
GAM FILLING
OSITE FILLING
AL RESTORATION
T CROWN
PROPHYLAXIS
OXIDE UEGENOL FILLING
ORARY FILLING
RRED TO PRIVATE DENTIST
UPTED
NTIST
er printed name)
DEPARTMENT OF EDUCATION
4A
Region
CAVITE CITY
Division
Age:
Latest
REGIE B. PALAG
Name:
15
Sex
Event:
Birth Date
FOOTBALL
Parent/Guardian:
Coach:
NENETH P. MANRIQUE
GINGIVITIS
PRERIODICAL
DISEASE
MALOCCLUSION
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
CLEFT PALATE
TREATMENT NEEDS
ROOT FRAGMENT
FLUOROSIS
OTHERS (Specify)
TEMPORARY TEETH
RIGHT
85 84 83 82 81 71 72 73 74 75
SUPERNUME
RARY
TOOTH
RETAINED
DECIDOUS
TEETH
DECUBITAL ULCER
CALCULUS
LEFT
CONDITION
YEAR LEVEL
DATE
EXAMINATION
SEALANT (GI)
PERMANENT FILLING
ART
EXTRACTION
ORAL PROPHYLAXIS
REFERRAL
OTHER ORAL TREATMEN
REMARKS
TEMPORARY TEETH
INDEX D.F.T.
NO. T /DECAYED
NO. T/ FILLED
TOTAL D.F.T.
TEMPORARY TEETH
INDEX D.F.T.
NO. T /DECAYED
NO. T/MISSING
NO. T/ FILLED
TOTAL D.F.T.
TOTAL SOUND TEETH
FOR FILLING
TOOTH
WITH TEMPORARY
HEAVY
SHADE
FILLING
RC - RECURRENT CARIES
RF - ROOT FRAGMENT
M - MISSING TOOTH
REMARKS:
Gn Gm Gs CMR () -
NORMAL
MODERATE GINGIVITIS
(1-2 QUADRANTS)
SEVERE GINGIVITIS
(3-4 QUADRANTS)
COMPLETE MOUTH REHAB
SOUND ERUPTED PERMANENT
TOOTH
Com
COMPOSITE F
JC
I
OP
ZOE
TF
R
UN
ARTIFICIAL REST
- JACKET CROW
- INLAY
- ORAL PROPHY
- ZINC OXIDE U
- TEMPORARY F
- REFERRED TO
- UNERUPTED
DENTIST
(signature over printe
PRC: LICENSE;
Latest 1 x 1 picture
DATE OF VISIT
R ACCOMPLISHMENT
ACTED PERMANENT TOOTH
ACTED TEMPORARY TOOTH
GAM FILLING
OSITE FILLING
AL RESTORATION
T CROWN
PROPHYLAXIS
OXIDE UEGENOL FILLING
ORARY FILLING
RRED TO PRIVATE DENTIST
UPTED
NTIST
er printed name)
DEPARTMENT OF EDUCATION
4A
Region
CAVITE CITY
Division
Name:
Age:
Latest
Sex
Event:
Birth Date
FOOTBALL
Parent/Guardian:
Coach:
NENETH P. MANRIQUE
GINGIVITIS
PRERIODICAL
DISEASE
MALOCCLUSION
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
CLEFT PALATE
TREATMENT NEEDS
ROOT FRAGMENT
FLUOROSIS
OTHERS (Specify)
TEMPORARY TEETH
RIGHT
85 84 83 82 81 71 72 73 74 75
SUPERNUME
RARY
TOOTH
RETAINED
DECIDOUS
TEETH
DECUBITAL ULCER
CALCULUS
LEFT
CONDITION
YEAR LEVEL
DATE
EXAMINATION
SEALANT (GI)
PERMANENT FILLING
ART
EXTRACTION
ORAL PROPHYLAXIS
REFERRAL
OTHER ORAL TREATMEN
REMARKS
TEMPORARY TEETH
INDEX D.F.T.
NO. T /DECAYED
NO. T/ FILLED
TOTAL D.F.T.
TEMPORARY TEETH
INDEX D.F.T.
NO. T /DECAYED
NO. T/MISSING
NO. T/ FILLED
TOTAL D.F.T.
TOTAL SOUND TEETH
FOR FILLING
TOOTH
WITH TEMPORARY
HEAVY
SHADE
FILLING
RC - RECURRENT CARIES
RF - ROOT FRAGMENT
M - MISSING TOOTH
REMARKS:
Gn Gm Gs CMR () -
NORMAL
MODERATE GINGIVITIS
(1-2 QUADRANTS)
SEVERE GINGIVITIS
(3-4 QUADRANTS)
COMPLETE MOUTH REHAB
SOUND ERUPTED PERMANENT
TOOTH
Com
COMPOSITE F
JC
I
OP
ZOE
TF
R
UN
ARTIFICIAL REST
- JACKET CROW
- INLAY
- ORAL PROPHY
- ZINC OXIDE U
- TEMPORARY F
- REFERRED TO
- UNERUPTED
DENTIST
(signature over printe
PRC: LICENSE;
Latest 1 x 1 picture
DATE OF VISIT
R ACCOMPLISHMENT
ACTED PERMANENT TOOTH
ACTED TEMPORARY TOOTH
GAM FILLING
OSITE FILLING
AL RESTORATION
T CROWN
PROPHYLAXIS
OXIDE UEGENOL FILLING
ORARY FILLING
RRED TO PRIVATE DENTIST
UPTED
NTIST
er printed name)
DEPARTMENT OF EDUCATION
4A
Region
CAVITE CITY
Division
Name:
Age:
16
Sex
Event:
Latest
Birth Date
JAN 1, 1999
FOOTBALL
Parent/Guardian:
Coach:
NENETH P. MANRIQUE
GINGIVITIS
PRERIODICAL
DISEASE
MALOCCLUSION
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
CLEFT PALATE
TREATMENT NEEDS
ROOT FRAGMENT
FLUOROSIS
OTHERS (Specify)
TEMPORARY TEETH
RIGHT
85 84 83 82 81 71 72 73 74 75
SUPERNUME
RARY
TOOTH
RETAINED
DECIDOUS
TEETH
DECUBITAL ULCER
CALCULUS
LEFT
CONDITION
YEAR LEVEL
DATE
EXAMINATION
SEALANT (GI)
PERMANENT FILLING
ART
EXTRACTION
ORAL PROPHYLAXIS
REFERRAL
OTHER ORAL TREATMEN
REMARKS
TEMPORARY TEETH
INDEX D.F.T.
NO. T /DECAYED
NO. T/ FILLED
TOTAL D.F.T.
TEMPORARY TEETH
INDEX D.F.T.
NO. T /DECAYED
NO. T/MISSING
NO. T/ FILLED
TOTAL D.F.T.
TOTAL SOUND TEETH
FOR FILLING
TOOTH
WITH TEMPORARY
HEAVY
SHADE
FILLING
RC - RECURRENT CARIES
RF - ROOT FRAGMENT
M - MISSING TOOTH
REMARKS:
Gn Gm Gs CMR () -
NORMAL
MODERATE GINGIVITIS
(1-2 QUADRANTS)
SEVERE GINGIVITIS
(3-4 QUADRANTS)
COMPLETE MOUTH REHAB
SOUND ERUPTED PERMANENT
TOOTH
Com
COMPOSITE F
JC
I
OP
ZOE
TF
R
UN
ARTIFICIAL REST
- JACKET CROW
- INLAY
- ORAL PROPHY
- ZINC OXIDE U
- TEMPORARY F
- REFERRED TO
- UNERUPTED
DENTIST
(signature over printe
PRC: LICENSE;
Latest 1 x 1 picture
DATE OF VISIT
R ACCOMPLISHMENT
ACTED PERMANENT TOOTH
ACTED TEMPORARY TOOTH
GAM FILLING
OSITE FILLING
AL RESTORATION
T CROWN
PROPHYLAXIS
OXIDE UEGENOL FILLING
ORARY FILLING
RRED TO PRIVATE DENTIST
UPTED
NTIST
er printed name)
DEPARTMENT OF EDUCATION
4A
Region
CAVITE CITY
Division
Age:
Latest
Name:
14
Sex
Event:
Birth Date
DEC. 6, 2001
FOOTBALL
Parent/Guardian:
Coach:
NENETH P. MANRIQUE
GINGIVITIS
PRERIODICAL
DISEASE
MALOCCLUSION
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
CLEFT PALATE
TREATMENT NEEDS
ROOT FRAGMENT
FLUOROSIS
OTHERS (Specify)
TEMPORARY TEETH
RIGHT
85 84 83 82 81 71 72 73 74 75
SUPERNUME
RARY
TOOTH
RETAINED
DECIDOUS
TEETH
DECUBITAL ULCER
CALCULUS
LEFT
CONDITION
YEAR LEVEL
DATE
EXAMINATION
SEALANT (GI)
PERMANENT FILLING
ART
EXTRACTION
ORAL PROPHYLAXIS
REFERRAL
OTHER ORAL TREATMEN
REMARKS
TEMPORARY TEETH
INDEX D.F.T.
NO. T /DECAYED
NO. T/ FILLED
TOTAL D.F.T.
TEMPORARY TEETH
INDEX D.F.T.
NO. T /DECAYED
NO. T/MISSING
NO. T/ FILLED
TOTAL D.F.T.
TOTAL SOUND TEETH
FOR FILLING
TOOTH
WITH TEMPORARY
HEAVY
SHADE
FILLING
RC - RECURRENT CARIES
RF - ROOT FRAGMENT
M - MISSING TOOTH
REMARKS:
Gn Gm Gs CMR () -
NORMAL
MODERATE GINGIVITIS
(1-2 QUADRANTS)
SEVERE GINGIVITIS
(3-4 QUADRANTS)
COMPLETE MOUTH REHAB
SOUND ERUPTED PERMANENT
TOOTH
Com
COMPOSITE F
JC
I
OP
ZOE
TF
R
UN
ARTIFICIAL REST
- JACKET CROW
- INLAY
- ORAL PROPHY
- ZINC OXIDE U
- TEMPORARY F
- REFERRED TO
- UNERUPTED
DENTIST
(signature over printe
PRC: LICENSE;
Latest 1 x 1 picture
DATE OF VISIT
R ACCOMPLISHMENT
ACTED PERMANENT TOOTH
ACTED TEMPORARY TOOTH
GAM FILLING
OSITE FILLING
AL RESTORATION
T CROWN
PROPHYLAXIS
OXIDE UEGENOL FILLING
ORARY FILLING
RRED TO PRIVATE DENTIST
UPTED
NTIST
er printed name)
DEPARTMENT OF EDUCATION
4A
Region
CAVITE CITY
Division
Age:
Latest
Name:
15
Sex
Event:
Birth Date
JAN 9, 2000
FOOTBALL
Parent/Guardian:
Coach:
NENETH P. MANRIQUE
GINGIVITIS
PRERIODICAL
DISEASE
MALOCCLUSION
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
CLEFT PALATE
TREATMENT NEEDS
ROOT FRAGMENT
FLUOROSIS
OTHERS (Specify)
TEMPORARY TEETH
RIGHT
85 84 83 82 81 71 72 73 74 75
SUPERNUME
RARY
TOOTH
RETAINED
DECIDOUS
TEETH
DECUBITAL ULCER
CALCULUS
LEFT
CONDITION
YEAR LEVEL
DATE
EXAMINATION
SEALANT (GI)
PERMANENT FILLING
ART
EXTRACTION
ORAL PROPHYLAXIS
REFERRAL
OTHER ORAL TREATMEN
REMARKS
TEMPORARY TEETH
INDEX D.F.T.
NO. T /DECAYED
NO. T/ FILLED
TOTAL D.F.T.
TEMPORARY TEETH
INDEX D.F.T.
NO. T /DECAYED
NO. T/MISSING
NO. T/ FILLED
TOTAL D.F.T.
TOTAL SOUND TEETH
FOR FILLING
TOOTH
WITH TEMPORARY
HEAVY
SHADE
FILLING
RC - RECURRENT CARIES
RF - ROOT FRAGMENT
M - MISSING TOOTH
REMARKS:
Gn Gm Gs CMR () -
NORMAL
MODERATE GINGIVITIS
(1-2 QUADRANTS)
SEVERE GINGIVITIS
(3-4 QUADRANTS)
COMPLETE MOUTH REHAB
SOUND ERUPTED PERMANENT
TOOTH
Com
COMPOSITE F
JC
I
OP
ZOE
TF
R
UN
ARTIFICIAL REST
- JACKET CROW
- INLAY
- ORAL PROPHY
- ZINC OXIDE U
- TEMPORARY F
- REFERRED TO
- UNERUPTED
DENTIST
(signature over printe
PRC: LICENSE;
Latest 1 x 1 picture
DATE OF VISIT
R ACCOMPLISHMENT
ACTED PERMANENT TOOTH
ACTED TEMPORARY TOOTH
GAM FILLING
OSITE FILLING
AL RESTORATION
T CROWN
PROPHYLAXIS
OXIDE UEGENOL FILLING
ORARY FILLING
RRED TO PRIVATE DENTIST
UPTED
NTIST
er printed name)
DEPARTMENT OF EDUCATION
4A
Region
CAVITE CITY
Division
Age:
Latest
JUFEL T. FLAUTA
Name:
15
Sex
Event:
Birth Date
FOOTBALL
Parent/Guardian:
Coach:
NENETH P. MANRIQUE
GINGIVITIS
PRERIODICAL
DISEASE
MALOCCLUSION
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
CLEFT PALATE
TREATMENT NEEDS
ROOT FRAGMENT
FLUOROSIS
OTHERS (Specify)
TEMPORARY TEETH
RIGHT
85 84 83 82 81 71 72 73 74 75
SUPERNUME
RARY
TOOTH
RETAINED
DECIDOUS
TEETH
DECUBITAL ULCER
CALCULUS
LEFT
CONDITION
YEAR LEVEL
DATE
EXAMINATION
SEALANT (GI)
PERMANENT FILLING
ART
EXTRACTION
ORAL PROPHYLAXIS
REFERRAL
OTHER ORAL TREATMEN
REMARKS
TEMPORARY TEETH
INDEX D.F.T.
NO. T /DECAYED
NO. T/ FILLED
TOTAL D.F.T.
TEMPORARY TEETH
INDEX D.F.T.
NO. T /DECAYED
NO. T/MISSING
NO. T/ FILLED
TOTAL D.F.T.
TOTAL SOUND TEETH
FOR FILLING
TOOTH
WITH TEMPORARY
HEAVY
SHADE
FILLING
RC - RECURRENT CARIES
RF - ROOT FRAGMENT
M - MISSING TOOTH
REMARKS:
Gn Gm Gs CMR () -
NORMAL
MODERATE GINGIVITIS
(1-2 QUADRANTS)
SEVERE GINGIVITIS
(3-4 QUADRANTS)
COMPLETE MOUTH REHAB
SOUND ERUPTED PERMANENT
TOOTH
Com
COMPOSITE F
JC
I
OP
ZOE
TF
R
UN
ARTIFICIAL REST
- JACKET CROW
- INLAY
- ORAL PROPHY
- ZINC OXIDE U
- TEMPORARY F
- REFERRED TO
- UNERUPTED
DENTIST
(signature over printe
PRC: LICENSE;
Latest 1 x 1 picture
DATE OF VISIT
R ACCOMPLISHMENT
ACTED PERMANENT TOOTH
ACTED TEMPORARY TOOTH
GAM FILLING
OSITE FILLING
AL RESTORATION
T CROWN
PROPHYLAXIS
OXIDE UEGENOL FILLING
ORARY FILLING
RRED TO PRIVATE DENTIST
UPTED
NTIST
er printed name)
DEPARTMENT OF EDUCATION
4A
Region
CAVITE CITY
Division
Name:
Age:
Latest
ACE P. URUBIO
14
Sex
Event:
Birth Date
FOOTBALL
Parent/Guardian:
Coach:
NENETH P. MANRIQUE
GINGIVITIS
PRERIODICAL
DISEASE
MALOCCLUSION
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
CLEFT PALATE
TREATMENT NEEDS
ROOT FRAGMENT
FLUOROSIS
OTHERS (Specify)
TEMPORARY TEETH
RIGHT
85 84 83 82 81 71 72 73 74 75
SUPERNUME
RARY
TOOTH
RETAINED
DECIDOUS
TEETH
DECUBITAL ULCER
CALCULUS
LEFT
CONDITION
YEAR LEVEL
DATE
EXAMINATION
SEALANT (GI)
PERMANENT FILLING
ART
EXTRACTION
ORAL PROPHYLAXIS
REFERRAL
OTHER ORAL TREATMEN
REMARKS
TEMPORARY TEETH
INDEX D.F.T.
NO. T /DECAYED
NO. T/ FILLED
TOTAL D.F.T.
TEMPORARY TEETH
INDEX D.F.T.
NO. T /DECAYED
NO. T/MISSING
NO. T/ FILLED
TOTAL D.F.T.
TOTAL SOUND TEETH
FOR FILLING
TOOTH
WITH TEMPORARY
HEAVY
SHADE
FILLING
RC - RECURRENT CARIES
RF - ROOT FRAGMENT
M - MISSING TOOTH
REMARKS:
Gn Gm Gs CMR () -
NORMAL
MODERATE GINGIVITIS
(1-2 QUADRANTS)
SEVERE GINGIVITIS
(3-4 QUADRANTS)
COMPLETE MOUTH REHAB
SOUND ERUPTED PERMANENT
TOOTH
Com
COMPOSITE F
JC
I
OP
ZOE
TF
R
UN
ARTIFICIAL REST
- JACKET CROW
- INLAY
- ORAL PROPHY
- ZINC OXIDE U
- TEMPORARY F
- REFERRED TO
- UNERUPTED
DENTIST
(signature over printe
PRC: LICENSE;
Latest 1 x 1 picture
DATE OF VISIT
R ACCOMPLISHMENT
ACTED PERMANENT TOOTH
ACTED TEMPORARY TOOTH
GAM FILLING
OSITE FILLING
AL RESTORATION
T CROWN
PROPHYLAXIS
OXIDE UEGENOL FILLING
ORARY FILLING
RRED TO PRIVATE DENTIST
UPTED
NTIST
er printed name)
DEPARTMENT OF EDUCATION
4A
Region
CAVITE CITY
Division
Name:
Age:
15
Sex
Event:
Latest
Birth Date
FOOTBALL
Parent/Guardian:
Coach:
NENETH P. MANRIQUE
GINGIVITIS
PRERIODICAL
DISEASE
MALOCCLUSION
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
CLEFT PALATE
TREATMENT NEEDS
ROOT FRAGMENT
FLUOROSIS
OTHERS (Specify)
TEMPORARY TEETH
RIGHT
85 84 83 82 81 71 72 73 74 75
SUPERNUME
RARY
TOOTH
RETAINED
DECIDOUS
TEETH
DECUBITAL ULCER
CALCULUS
LEFT
CONDITION
YEAR LEVEL
DATE
EXAMINATION
SEALANT (GI)
PERMANENT FILLING
ART
EXTRACTION
ORAL PROPHYLAXIS
REFERRAL
OTHER ORAL TREATMEN
REMARKS
TEMPORARY TEETH
INDEX D.F.T.
NO. T /DECAYED
NO. T/ FILLED
TOTAL D.F.T.
TEMPORARY TEETH
INDEX D.F.T.
NO. T /DECAYED
NO. T/MISSING
NO. T/ FILLED
TOTAL D.F.T.
TOTAL SOUND TEETH
FOR FILLING
TOOTH
WITH TEMPORARY
HEAVY
SHADE
FILLING
RC - RECURRENT CARIES
RF - ROOT FRAGMENT
M - MISSING TOOTH
REMARKS:
Gn Gm Gs CMR () -
NORMAL
MODERATE GINGIVITIS
(1-2 QUADRANTS)
SEVERE GINGIVITIS
(3-4 QUADRANTS)
COMPLETE MOUTH REHAB
SOUND ERUPTED PERMANENT
TOOTH
Com
COMPOSITE F
JC
I
OP
ZOE
TF
R
UN
ARTIFICIAL REST
- JACKET CROW
- INLAY
- ORAL PROPHY
- ZINC OXIDE U
- TEMPORARY F
- REFERRED TO
- UNERUPTED
DENTIST
(signature over printe
PRC: LICENSE;
Latest 1 x 1 picture
DATE OF VISIT
R ACCOMPLISHMENT
ACTED PERMANENT TOOTH
ACTED TEMPORARY TOOTH
GAM FILLING
OSITE FILLING
AL RESTORATION
T CROWN
PROPHYLAXIS
OXIDE UEGENOL FILLING
ORARY FILLING
RRED TO PRIVATE DENTIST
UPTED
NTIST
er printed name)