TFSS Form No.

003 DC

Republic of the Philippines

DEPARTMENT OF EDUCATION
4A
Region

CAVITE CITY
Division

DENTAL HEALTH RECORD

JAN. 5, 2015
Date

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

CONDITION AND TREATMENT NEEDS

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

SYMBOLS FOR MOUTH EXAMINATION

X - TOOTH INDICATED
DU - DECUBITAL ULCER
FOR EXTRACTION
MAL - MALOCLUSSION
F - TOOTH INDICATED
FLU - FLOUROSIS

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

SYMBOLS FOR ACCO

Xt - EXTRACTED P
xt - EXTRACTED T
Am - AMALGAM FIL

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)

TFSS Form No. 003 DC

Republic of the Philippines

DEPARTMENT OF EDUCATION
4A
Region

CAVITE CITY
Division

DENTAL HEALTH RECORD

JAN. 5, 2015
Date

Name:

Latest

ROGER BRIAM ALIH S. BRIZUELA

Age:

14

Event:

Sex

Birth Date

JAN 25, 2001

FOOTBALL

Parent/Guardian:
Coach:

NENETH P. MANRIQUE
GINGIVITIS

CONDITION AND TREATMENT NEEDS

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

SYMBOLS FOR MOUTH EXAMINATION

X - TOOTH INDICATED
DU - DECUBITAL ULCER
FOR EXTRACTION
MAL - MALOCLUSSION
F - TOOTH INDICATED
FLU - FLOUROSIS

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

SYMBOLS FOR ACCO

Xt - EXTRACTED P
xt - EXTRACTED T
Am - AMALGAM FIL

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)

TFSS Form No. 003 DC

Republic of the Philippines

DEPARTMENT OF EDUCATION
4A
Region

CAVITE CITY
Division

DENTAL HEALTH RECORD

JAN. 5, 2015
Date

Name:
Age:

Latest

MARK ASHLEY S. ANDRADE

14

Sex

Event:

Birth Date

OCT. 6, 2001

FOOTBALL

Parent/Guardian:
Coach:

NENETH P. MANRIQUE
GINGIVITIS

CONDITION AND TREATMENT NEEDS

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

SYMBOLS FOR MOUTH EXAMINATION

X - TOOTH INDICATED
DU - DECUBITAL ULCER
FOR EXTRACTION
MAL - MALOCLUSSION
F - TOOTH INDICATED
FLU - FLOUROSIS

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

SYMBOLS FOR ACCO

Xt - EXTRACTED P
xt - EXTRACTED T
Am - AMALGAM FIL

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)

TFSS Form No. 003 DC

Republic of the Philippines

DEPARTMENT OF EDUCATION
4A
Region

CAVITE CITY
Division

DENTAL HEALTH RECORD

JAN. 5, 2015
Date

Age:

Latest

JAKE RYAN T. VILORIA

Name:
14

Sex

Event:

Birth Date

DEC 20, 2001

FOOTBALL

Parent/Guardian:
Coach:

NENETH P. MANRIQUE
GINGIVITIS

CONDITION AND TREATMENT NEEDS

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

SYMBOLS FOR MOUTH EXAMINATION

X - TOOTH INDICATED
DU - DECUBITAL ULCER
FOR EXTRACTION
MAL - MALOCLUSSION
F - TOOTH INDICATED
FLU - FLOUROSIS

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

SYMBOLS FOR ACCO

Xt - EXTRACTED P
xt - EXTRACTED T
Am - AMALGAM FIL

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)

TFSS Form No. 003 DC

Republic of the Philippines

DEPARTMENT OF EDUCATION
4A
Region

CAVITE CITY
Division

DENTAL HEALTH RECORD

JAN. 5, 2015
Date

Age:

Latest

REGIE B. PALAG

Name:
15

Sex

Event:

Birth Date

AUG. 24, 2000

FOOTBALL

Parent/Guardian:
Coach:

NENETH P. MANRIQUE
GINGIVITIS

CONDITION AND TREATMENT NEEDS

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

SYMBOLS FOR MOUTH EXAMINATION

X - TOOTH INDICATED
DU - DECUBITAL ULCER
FOR EXTRACTION
MAL - MALOCLUSSION
F - TOOTH INDICATED
FLU - FLOUROSIS

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

SYMBOLS FOR ACCO

Xt - EXTRACTED P
xt - EXTRACTED T
Am - AMALGAM FIL

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)

TFSS Form No. 003 DC

Republic of the Philippines

DEPARTMENT OF EDUCATION
4A
Region

CAVITE CITY
Division

DENTAL HEALTH RECORD

JAN. 5, 2015
Date

Name:
Age:

Latest

JOHN CARLO DM. ARCALLANA

15

Sex

Event:

Birth Date

OCT 15, 2000

FOOTBALL

Parent/Guardian:
Coach:

NENETH P. MANRIQUE
GINGIVITIS

CONDITION AND TREATMENT NEEDS

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

SYMBOLS FOR MOUTH EXAMINATION

X - TOOTH INDICATED
DU - DECUBITAL ULCER
FOR EXTRACTION
MAL - MALOCLUSSION
F - TOOTH INDICATED
FLU - FLOUROSIS

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

SYMBOLS FOR ACCO

Xt - EXTRACTED P
xt - EXTRACTED T
Am - AMALGAM FIL

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)

TFSS Form No. 003 DC

Republic of the Philippines

DEPARTMENT OF EDUCATION
4A
Region

CAVITE CITY
Division

DENTAL HEALTH RECORD

JAN. 5, 2015
Date

CEDRICK JOY C. MAGNABIJON

Name:
Age:

16

Sex

Event:

Latest
Birth Date

JAN 1, 1999

FOOTBALL

Parent/Guardian:
Coach:

NENETH P. MANRIQUE
GINGIVITIS

CONDITION AND TREATMENT NEEDS

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

SYMBOLS FOR MOUTH EXAMINATION

X - TOOTH INDICATED
DU - DECUBITAL ULCER
FOR EXTRACTION
MAL - MALOCLUSSION
F - TOOTH INDICATED
FLU - FLOUROSIS

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

SYMBOLS FOR ACCO

Xt - EXTRACTED P
xt - EXTRACTED T
Am - AMALGAM FIL

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)

TFSS Form No. 003 DC

Republic of the Philippines

DEPARTMENT OF EDUCATION
4A
Region

CAVITE CITY
Division

DENTAL HEALTH RECORD

JAN. 5, 2015
Date

Age:

Latest

JULIUS CESAR M. ANCHETA

Name:

14

Sex

Event:

Birth Date

DEC. 6, 2001

FOOTBALL

Parent/Guardian:
Coach:

NENETH P. MANRIQUE
GINGIVITIS

CONDITION AND TREATMENT NEEDS

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

SYMBOLS FOR MOUTH EXAMINATION

X - TOOTH INDICATED
DU - DECUBITAL ULCER
FOR EXTRACTION
MAL - MALOCLUSSION
F - TOOTH INDICATED
FLU - FLOUROSIS

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

SYMBOLS FOR ACCO

Xt - EXTRACTED P
xt - EXTRACTED T
Am - AMALGAM FIL

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)

TFSS Form No. 003 DC

Republic of the Philippines

DEPARTMENT OF EDUCATION
4A
Region

CAVITE CITY
Division

DENTAL HEALTH RECORD

JAN. 5, 2015
Date

Age:

Latest

NHIL KENNEDY S. SORIANO

Name:

15

Sex

Event:

Birth Date

JAN 9, 2000

FOOTBALL

Parent/Guardian:
Coach:

NENETH P. MANRIQUE
GINGIVITIS

CONDITION AND TREATMENT NEEDS

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

SYMBOLS FOR MOUTH EXAMINATION

X - TOOTH INDICATED
DU - DECUBITAL ULCER
FOR EXTRACTION
MAL - MALOCLUSSION
F - TOOTH INDICATED
FLU - FLOUROSIS

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

SYMBOLS FOR ACCO

Xt - EXTRACTED P
xt - EXTRACTED T
Am - AMALGAM FIL

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)

TFSS Form No. 003 DC

Republic of the Philippines

DEPARTMENT OF EDUCATION
4A
Region

CAVITE CITY
Division

DENTAL HEALTH RECORD

JAN. 5, 2015
Date

Age:

Latest

JUFEL T. FLAUTA

Name:

15

Sex

Event:

Birth Date

JAN. 13, 2000

FOOTBALL

Parent/Guardian:
Coach:

NENETH P. MANRIQUE
GINGIVITIS

CONDITION AND TREATMENT NEEDS

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

SYMBOLS FOR MOUTH EXAMINATION

X - TOOTH INDICATED
DU - DECUBITAL ULCER
FOR EXTRACTION
MAL - MALOCLUSSION
F - TOOTH INDICATED
FLU - FLOUROSIS

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

SYMBOLS FOR ACCO

Xt - EXTRACTED P
xt - EXTRACTED T
Am - AMALGAM FIL

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)

TFSS Form No. 003 DC

Republic of the Philippines

DEPARTMENT OF EDUCATION
4A
Region

CAVITE CITY
Division

DENTAL HEALTH RECORD

JAN. 5, 2015
Date

Name:
Age:

Latest

ACE P. URUBIO
14

Sex

Event:

Birth Date

OCT. 19, 2001

FOOTBALL

Parent/Guardian:
Coach:

NENETH P. MANRIQUE
GINGIVITIS

CONDITION AND TREATMENT NEEDS

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

SYMBOLS FOR MOUTH EXAMINATION

X - TOOTH INDICATED
DU - DECUBITAL ULCER
FOR EXTRACTION
MAL - MALOCLUSSION
F - TOOTH INDICATED
FLU - FLOUROSIS

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

SYMBOLS FOR ACCO

Xt - EXTRACTED P
xt - EXTRACTED T
Am - AMALGAM FIL

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)

TFSS Form No. 003 DC

Republic of the Philippines

DEPARTMENT OF EDUCATION
4A
Region

CAVITE CITY
Division

DENTAL HEALTH RECORD

JAN. 5, 2015
Date

Christian Mill J. Aguilar

Name:
Age:

15

Sex

Event:

Latest
Birth Date

JAN. 24, 2000

FOOTBALL

Parent/Guardian:
Coach:

NENETH P. MANRIQUE
GINGIVITIS

CONDITION AND TREATMENT NEEDS

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

SYMBOLS FOR MOUTH EXAMINATION

X - TOOTH INDICATED
DU - DECUBITAL ULCER
FOR EXTRACTION
MAL - MALOCLUSSION
F - TOOTH INDICATED
FLU - FLOUROSIS

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

SYMBOLS FOR ACCO

Xt - EXTRACTED P
xt - EXTRACTED T
Am - AMALGAM FIL

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)