TFSS Form No.

003 DC
Republic of the Philippines
DEPARTMENT OF EDUCATION

Region

Division

DENTAL HEALTH RECORD

Date

Name: Latest 1½ x 1½ picture

Age: Sex Birth Date

Event:
Parent/Guardian:
Coach:

CONDITION AND TREATMENT NEEDS Gingivitis

CONDITION Per. Disease
RIGHT 55 54 53 52 51 61 62 63 64 65 LEFT Malocclusion
TEMPORARY TEETH Sup. Tooth
R. D. T.
Dec. Ulcer
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 Calculus
PERMANENT TEETH Cleft Lip/Palate
Root Fragment
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 Fluorosis
CONDITION Others
TREATMENT NEEDS (Specify)
TEMPORARY TEETH
RIGHT
85 84 83 82 81 71 72 73 74 75 LEFT

CONDITION

TEMPORARY TEETH DATE OF VISITS

GRADE/YEAR LEVEL REMARKS Index d.f.t.
DATE No. t /decayed
EXAMINATION No. t/ filled
SEALANT (GI) Total d.f.t.
PERMANENT FILLING
ART
EXTRACTION PERMANENT TEETH DATE OF VISITS
ORAL PROPHYLAXIS Index D.M.F.
REFERRAL No. T /Decayed
OTHER ORAL TREATMENT No. T/Missing
No. T/ Filled
Total D.M.F.
Total sound teeth

SYMBOLS FOR MOUTH EXAMINATION SYMBOLS FOR ACCOMPLISHMENT

X - TOOTH INDICATED
FOR EXTRACTION
F - TOOTH INDICATED
FOR FILLING
OUTLINE OF FILLING - TOOTH W/
TEMPORARY FILLING
HEAVY - PERMANENT FILLING
SHADE
RC - RECURRENT CARIES
RF - ROOT FRAGMENT
M - MISSING TOOTH
DU - DECUBITAL ULCER Xt - EXTRACTED PERMANENT TOOTH
MAL - MALOCLUSSION xt - EXTRACTED TEMPORARY TOOTH
FLU - FLUOROSIS Am - AMALGAM FILLING
Gn - NORMAL Com - COMPOSITE FILLING
Gm - MODERATE GINGIVITIS
(1-2 QUADRANTS)
Gs - SEVERE GINGIVITIS
(3-4 QUADRANTS) ARTIFICIAL RESTORATION
CMR - COMPLETE MOUTH REHAB JC - JACKET CROWN
(√) - SOUND ERUPTED PERMANENT I - INLAY
TOOTH OP - ORAL PROPHYLAXIS
ZOE - ZINC OXIDE EUGENOL FILLING
TF - TEMPORARY FILLING
 R - REFERRED TO PRIVATE DENTIST
REMARKS: UN - UNERUPTED

DENTIST
(signature over printed name)
PRC: LICENSE;