Republic of the Philippines
Department of Health A. Check (/) if present (x) if absent B. Indicate Number
Regional Office__ Date of Oral Examination No. of Perm. Teeth Present
LiComCoClinic_Form No. 05 _________________ Dental Caries No. of Sound Perm. Teeth
(Municipality/City/Province) Ging./Periodontal Disease No. of Decayed Teeth (D)
Individual Patient Treatment Record Oral Debris No. of Missing Teeth (M)
Calculus No. of Filled Teeth (F)
(DENTAL)
Abnormal Growth Total DMF Teeth
Cleft Lip/ Palate No. of Temp. Teeth Present
Name _____________________________________________________________________________ Others No. of Sound Temp. Teeth
Surname First Name Middle Initial
(Supernumerary,Mesiodens Present
Date of Birth _______________________________________________________________________
,etc)
Place of Birth ______________________________________________________ Age _____ Sex _____
Address ________________________________________________________________________ No. of Decayed Teeth (d)
Occupation _________________________________________________________________________ No. of Filled Teeth (f)
Parent/Guardian _____________________________________________________________________ Total df Teeth
A. Oral Health Condition
Other Patient Information (Membership) Year I – Date
___ National Household Targeting System – Poverty Reduction (NHTS-PR) 55 54 53 52 51 61 62 63 64 65
___ Pantawid Pamilyang Pilipino Program (4Ps)
___ Indigenous People (IP) ___ Person With Disabilities (PWDs)
___ PhilHealth (Indicate Number) ___ SSS (Indicate Number) 18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
___ GSIS (Indicate Number) 48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
Vital Signs
Blood Pressure: _____________Pulse Rate: ___________Temperature: _______________
Medical History 85 84 82 81 71 72 73 74 75
Year II – Date
___ Allergies (Please specify) ________________ Hypertension/ CVA 55 54 53 52 51 61 62 63 64 65
___ Diabetes Mellitus ___ Blood Disorders
___ Cardiovascular / Heart Diseases ___ Thyroid Disorders
___ Hepatitis (Please specify type) ________ ___ Malignancy (Please specify) ___________ __
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
___ History of Previous Hospitalization:
Medical (Last Admission & Cause) __________________________________________ __ 48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
Surgical (Post-Operative) _____________________________________________________
___Blood transfusion (Month & Year) _______________________________________________
___Tattoo 85 84 83 82 81 71 72 73 74 75
Year III – Date
___Others (Please specify) ________________________________ 55 54 53 52 51 61 62 63 64 65
Conforme: ___________________________________________
Patient’s / Guardian’s Name and Signature 18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
Dietary Habits / Social History
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
___ Sugar Sweetened Beverages/Food (Amount, Frequency & Duration) ___________________
___ Use of Alcohol (Amount, Frequency & Duration) ___________________________________
___ Use of Tobacco (Amount, Frequency & Duration) __________________________________ 85 84 83 82 81 71 72 73 74 75
___ Betel Nut Chewing (Amount, Frequency & Duration) ________________________________
Year IV – Date
55 54 53 52 51 61 62 63 64 65 Date Sealant/PF/TF/X/O
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
85 84 83 82 81 71 72 73 74 75
Date Sealant/PF/TF/X/O
85 84 83 82 81 71 72 73 74 75
Year V – Date
55 54 53 52 51 61 62 63 64 65
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
Date Sealant/PF/TF/X/O
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
85 84 83 82 81 71 72 73 74 75
Capital letters shall be used for recording the condition of permanent dentition and small letters
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
for the status of temporary dentition
Legend:
Legend:
Permanent Tooth/Condition Temporary
S - Sealant X - Extraction
Sound sealed
PF - Permanent Filling (composite, Am/ART) O – Others
D Decayed d
TF – Temporary
F Filled f
M Missing e
SUMMARY OF SERVICES RENDERED
X Indicated for Extraction x
Un Unerupted un Oral Tmp. Perm. F tx Consult Remar Signat
S Supermumenary Tooth s Date PPS Exo Others ks ure
Prophy. Filling Filling (# app) ation
JC Jacket Crown jc
P Pontic p
A. Services Monitoring Chart
Date Sealant/PF/TF/X/O
55 54 53 52 51 61 62 63 64 65
