Republic of the Philippines

Department of Education
Region I
SCHOOLS DIVISION OF ILOCOS NORTE
Laoag City

BUREAU OF LEARNER SUPPORT SERVICES-SCHOOL HEALTH DIVISION

SCHOOLS DIVISION OF ILOCOS NORTE
SCHOOL HEALTH EXAMINATION CARD

NAME: _____________________________________ SCHOOL ID:____________ LRN:__________________

LAST FIRST MIDDLE

DATE OF BIRTH:__________________________ RELIGION:______________________________________

BIRTH PLACE:____________________________ DIVISION:_______________________________________
PARENT/GUARDIAN:______________________________________ TEL. NO.:________________________
ADDRESS:_______________________________________________________________________________

SCHOOL ORAL HEALTH EXAMINATION

GRADE 7 S.Y._______________ GRADE 8: S.Y._____________

GRADE 8: S.Y._______________ GRADE 10 S.Y.________________

 GRADE 11 S.Y._______________ GRADE 12 S.Y______________

ORAL HEALTH CONDITION

Kinder 1
7
2
8
3
9
4
10
5
11
6
12
Gingivitis
Periodontal Desease
Malocclusion
Supernumerary teeth
Retained deciduous teeth
Decubital ulcer
Calculus
Cleft lip / palate
Root fragment
Fluorosis
Others, specify

TEMPORARY TEETH dft Index PERMANENT TEETH

Index d.f.t. Kinder 1 2 3 4 5 6 Kinder 1 2 3 4 5 6
Index D.M.F.T.
No. T/decayed 7 8 9 10 11 12
No. T/filled No. T/decayed
Total d.f.t. No. T/Missing
For Extraction No. T/filled
For Filling Total D.M.F.T.
Total Sound Teeth Total Sound Teeth
For Extraction
For Filling
Total Sound Teeth
 SYMBOL FOR MOUTH EXAMINATION
X – Carious tooth indicates for extraction (√) – Sound/erupted Permanent Tooth FB – Fixed Bridge
d – Carious tooth indicated for filling FRS – Pit and Fissure Sealant CD – Complete Denture
RF – Root fragment JC – Jacket Crown GI – Glass Ionomer
M – Missing tooth PFS – Pontic CO – Composite
F2 – Permanently filled tooth with RPD – Removable Portal Denture AM – Amalgam
recurrence of decay

INTERVENTION/TREATMENT RECORD
Date Chief Complaint Intervention / Treatment Done Remarks Attended by (Name/Position)