Republic of the Philippines

Department of Health
CENTER FOR HEALTH DEVELOPMENT IV - A
CITY HEALTH OFFICE - II
Dasmarias City, Cavite
Individual Patients Treatment Record
Date: ______________
Patients Name: _________________________________________________________
Surname First name M.I.
Parents Name (If patient is a child): ________________________________________
Address: __________________________ Place of Birth: _______________________
Date of Birth: ____________ AGE: _______ SEX: _____ CIVIL STATUS: ___________
Tel #: _______________ Occupation:____________________
Oral Health Condition
A. Check () if present (X) if absent B. Indicate Number
Date of Oral Examination No. of Perm. Teeth Present
Dental Caries No. of Perm. Sound Teeth
Gingivitis / Periodontal
Disease
No. of Decayed Teeth (D)
Debris No. of Missing Teeth (M)
Calculus No. of Filled Teeth (F)
Abnormal Growth Total DMF Teeth
Cleft Lip / Palate No. of Temp. Teeth
Others (supernumerary /
mesiodens, etc.)
No. of Temp. Sound Teeth
No. of Decayed Teeth (d)
No. of Filled teeth (f )
Total df Teeth
Oral Health Condition
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
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
Answer to the following questions are for our records only and will be considered condential.
1. Are you under the care of a physician? YES NO
a. If so, what was the problem? ______________________________________
b. The Name and Address of my physician is: ___________________________
2. Have you been hospitalized or had a serious illness within the past ve years?
YES NO
a. If so, what was the problem? ______________________________________
3. Do you have or had:
a. Rheumatic Heart Disease YES NO
b. Congenital Heart Disease YES NO
c. Fainting Spiels, Epilepsy YES NO
d. Hepatitis or Liver Disease YES NO
e. Anemia YES NO
f. Stomach Ulcer YES NO
g. Asthma YES NO
h. Cardiovascular Disease (Heart Trouble, Heart Attack, High Blood Pressure, Stroke)
YES NO
i. Allergy to food, specify _______________________________________________
to drugs, specify ______________________________________________
to local anesthesia, specify _____________________________________
j. Diabetes YES NO
k. Skin Rash YES NO
l. Kidney Trouble YES NO
m. Tuberculosis YES NO
n. Low Blood Pressure YES NO
o. Others _____________________________________________________________
4. Have you had abnormal bleeding associated with previous extractions, surgery or trauma?
YES NO
5. Are you taking any drug or medicine? If so, specify
_______________________________________________________________________
6. Have you had any serious trouble associated with previous dental treatment?
YES NO
7. WOMEN ONLY: Are you pregnant? YES NO
CHIEF DENTAL COMPLAINT: _________________________________________________
Summary of Service Rendered
Date
Oral
Prophy
Temp
Filling
Perm.
Filling
Sealant Exo.
Fluo-
ride
Consul-
tation
Others Remarks Signature
________________________________ ________________________________
Signature of Dentist Signature of Patient