dental certificate

Republic of the Philippines DEPARTMENT OF EDUCATION CORDILLERA ADMINISTRATIVE REGION Region BAGUIO CITY Division DENTAL HEALTH RECORD Name: Age: Sex Birth Date Date Event: arent/Guardian: Coach: GINGIVITIS 55 54 53 52 51 61 62 63 64 65 MALOCCLUSION 18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 DECUBITAL ULCER 48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CALCULUS CLEFT PALATE ROOT FRAGMENT FLUOROSIS 85 84 83 82 81 71 72 73 74 75 OTHERS (Specify) DATE OF VISIT YEAR LEVEL REMARKS TEMPORARY TEETH DATE INDEX D.F.T. EXAMINATION NO. T /DECAYED SEALANT (GI) NO. T/ FILLED PERMANENT FILLING TOTAL D.F.T. ART EXTRACTION TEMPORARY TEETH ORAL PROPHYLAXIS INDEX D.F.T. REFERRAL NO. T /DECAYED OTHER ORAL TREATMENT NO. T/MISSING NO. T/ FILLED TOTAL D.F.T. TOTAL SOUND TEETH SYMBOLS FOR MOUTH EXAMINATION SYMBOLS FOR ACCOMPLISHMENT X - TOOTH INDICATED DU - DECUBITAL ULCER XT - EXTRACTED PERMANENT TOOTH FOR EXTRACTION MAL - MALOCLUSSION xt - EXTRACTED TEMPORARY TOOTH F - TOOTH INDICATED FLU - FLUOROSIS Am - AMALGAM FILLING FOR FILLING Gn - NORMAL Com - COMPOSITE FILLING - TOOTH WITH TEMPORARY Gm - MODERATE GINGIVITIS FILLING (1-2 QUADRANTS) ARTIFICIAL RESTORATION RC - RECURRENT CARIES Gs - SEVERE GINGIVITIS JC - JACKET CROWN RF - ROOT FRAGMENT (3-4 QUADRANTS) I - INLAY M - MISSING TOOTH CMR - COMPLETE MOUTH REHAB OP - ORAL PROPHYLAXIS (√) - SOUND ERUPTED PERMANENT ZOE - ZINC OXIDE UEGENOL FILLING TOOTH TF - TEMPORARY FILLING R - REFERRED TO PRIVATE DENTIST UN - UNERUPTED TOOTH Division Meet Remarks/Findings: DENTIST (signature over printed name) PRC: LICENSE: Date Examined: Regional Meet Remarks/Findings: DENTIST (signature over printed name) PRC: LICENSE: Date Examined: Palarong Pambansa Remarks/Findings: DENTIST (signature over printed name) PRC: LICENSE: Date Examined: FOR PALARONG PAMBANSA ONLY PERIODONTAL DISEASE SUPERNUMERAR Y TOOTH DECIDOUS TEETH HEAVY SHADE PERMANENT TEETH CONDITION TREATMENT NEEDS LEFT RIGHT CONDITION TEMPORARY TEETH TEMPORARY TEETH RIGHT CONDITION LEFT CONDITION AND TREATMENT NEEDS Latest 1½ x 1½ picture

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Palarong Pangbansa Form

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Republic of the PhilippinesDEPARTMENT OF EDUCATION

CORDILLERA ADMINISTRATIVE REGIONRegion

BAGUIO CITYDivision

DENTAL HEALTH RECORD

Name:

Age: Sex Birth Date Date

Event:

Parent/Guardian:

Coach:

GINGIVITIS

55 54 53 52 51 61 62 63 64 65MALOCCLUSION

18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28

DECUBITAL ULCER48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 CALCULUS

CLEFT PALATEROOT FRAGMENTFLUOROSIS

85 84 83 82 81 71 72 73 74 75 OTHERS (Specify)

DATE OF VISITYEAR LEVEL REMARKS TEMPORARY TEETH

DATE INDEX D.F.T.EXAMINATION NO. T /DECAYEDSEALANT (GI) NO. T/ FILLEDPERMANENT FILLING TOTAL D.F.T.ARTEXTRACTION TEMPORARY TEETHORAL PROPHYLAXIS INDEX D.F.T.REFERRAL NO. T /DECAYEDOTHER ORAL TREATMENT NO. T/MISSING

NO. T/ FILLEDTOTAL D.F.T.TOTAL SOUND TEETH

SYMBOLS FOR MOUTH EXAMINATION SYMBOLS FOR ACCOMPLISHMENTX - TOOTH INDICATED DU - DECUBITAL ULCER XT - EXTRACTED PERMANENT TOOTH

FOR EXTRACTION MAL - MALOCLUSSION xt - EXTRACTED TEMPORARY TOOTHF - TOOTH INDICATED FLU - FLUOROSIS Am - AMALGAM FILLING

FOR FILLING Gn - NORMAL Com - COMPOSITE FILLING- TOOTH WITH TEMPORARY Gm - MODERATE GINGIVITIS

FILLING (1-2 QUADRANTS) ARTIFICIAL RESTORATIONRC - RECURRENT CARIES Gs - SEVERE GINGIVITIS JC - JACKET CROWNRF - ROOT FRAGMENT (3-4 QUADRANTS) I - INLAYM - MISSING TOOTH CMR - COMPLETE MOUTH REHAB OP - ORAL PROPHYLAXIS

(√) - SOUND ERUPTED PERMANENT ZOE - ZINC OXIDE UEGENOL FILLING TOOTH TF - TEMPORARY FILLING

R - REFERRED TO PRIVATE DENTISTUN - UNERUPTED TOOTH

Division Meet Remarks/Findings:

DENTIST(signature over printed name)

PRC: LICENSE: Date Examined:Regional Meet Remarks/Findings:

DENTIST(signature over printed name)

PRC: LICENSE: Date Examined:Palarong Pambansa Remarks/Findings:

DENTIST(signature over printed name)

PRC: LICENSE: Date Examined:

FOR PALARONG PAMBANSA ONLY

PERIODONTAL DISEASE

SUPERNUMERARY TOOTHRETAINED DECIDOUS TEETH