UNIVERSITY HEALTH SERVICE

UNIVERSITY OF THE PHILIPPINES DILIMAN, QUEZON CITY ALLERGIC TO Student No. Date of Examination ____________________

DENTAL CLINIC
OUT PATIENT RECORD
PRINT NAME :
(LAST) (FIRST) (MIDDLE)

DATE OF BIRTH : ADDRESS : PARENT/GUARDIAN : ADDRESS :

AGE SEX SCHOOL/COLLEGE OFFICE/DEPARTMENT OCCUPATION RELATION

REL

CS

TEL. NO.

OFFICE/DEPT

MARKINGS ON BLOCKS FOR CONDITION OPERATION TREATMENT DONE EXISTING CONDITION

TREATMENT DONE EXISTING CONDITION

TREATMENT DONE EXISTING CONDITION

TREATMENT DONE EXISTING CONDITION

LEGEND:
C RF I A X AM DENTAL CARIES ROOT FRAGMENT IMPACTED ABRASIONS (CERVICAL) MISSING / EXTRACTED AMALGAM CO S MO CEO MI CEI COMPOSITE SEALANTS METAL ONLAY CERAMIC ONLAY METAL INLAY CERAMIC INLAY GJC AJC PJC MJC CD RPD GOLD JACKET CROWN ACRYLIC JACKET CROWN PORCELAIN JACKET CROWN METAL JACKET CROWN COMPLETE DENTURES REMOVABLE PARTIAL DENTURE

GINGIVITIS OCCLUSION N

MILD DISTO

MODERATE LOCALIZED MESIO

SEVERE GENERALIZED CROWDING OPEN BITE DEEP BITE

PERIODONTAL CONDITION HABITS : PRESENCE OF DENTO FACIAL ANOMALY :

DR.
EXAMINER

DMD

UPHS FORM NO. 2-C

Print Name __________________________________________________________________________________________ (Last) (First) (Middle) Age : ________ Sex : ___________ Civil Status : ____________

(Do not write on this side. To be filled out by your Physician)

Vital signs and anthropometric measurements: Pulse rate: ______beats/min. Height : ____________ cm. Blood Pressure: _________mmHg Weight : ____________ kg. Respiratory Rate: ________breaths/min. Body Mass Index : _______________ Temperature: _________

General Health Appearance : Excellent, good, fair, poor. Visual Acuity: FAR Right: Left: Without Glasses NEAR With Glasses/Contact Lens FAR NEAR

_____ _____ _____ _____ _____

Under (< 18.5) Good (18.5 - 24.9) Over (25 - 29.9) Obese I (30 - 39.9) Obese II ( 40)

______________ : _____________ ______________ : _____________

______________ : _____________ ______________ : _____________

Color vision : _____________________________________ Please check apporpriate box whether findings are normal or abnormal for each organ/system; if with abnormal findings, please describe findings below Organs/Systems: Normal Abnormal If abnormal, please describe findings Skin Head/Scalp Eyes Ears Nose Mouth/Oropharynx Neck Heart Lungs Back/Spine Abdomen Extremities Genito-urinary/Ano-reactal Neurologic

Chest x-ray findings: _________________________________________________________ Activity: I Unlimited II Unlimited with observation III Resticted and corrective IV Reconstructive V Activity

ASSESSMENT

RECOMMENDATIONS

Examined by: ___________________________________________ PRC Licence number: ____________________________________ Date examined: _________________________________________