THE MINISTRY OF HEALTH OF REPUBLIC INDONESIA

AGENCY OF HEALTH HUMAN RESOURCES DEVELOPMENT AND EMPOWERMENT

HEALTH POLYTHECNIC OF HEALTH MINISTRY IN YOGYAKARTA
St. Tata Bumi No. 3, Banyuraden, Gamping, Sleman, DI Yogyakarta Telp/F ax: (0274) 617601
http://www.poltekkes.jogja.ac.id e-mail: http://poltekkes.depkesyogya@gmail.com

NO MEDICAL HISTORY :………………..

NAME :………………..
Student ID Number :……………......

I. PATIENT IDENTITY

THE SCAN FORM OF DENTAL HOME CARE

Full Name : ………………………………..Male/Female Religion : ……………….
Place and Date Birth : ……………………………….. Blood Type : ……………….
Occupation : ……………………………......
Address : ………………………………..
Phone number : ………………………………..

II. SUBJECTIVE EXAMINATION

1. Chief Compliment :

2. Dental Medical History :

3. Generak Medical History :

4. Habits :

5. Others :

III. OBJETIVE EXAMINATION

1. Extra Oral Examination
a. Fac ial : Symmetry/Assymmetry
b. Lips : Normal/Abnormal
c. Lymph Node : Right : Palpable/ Not Palpable, Tough/Lenient, Pain/Painless
Left : Palpable/ Not Palpable, Tough/Lenient, Pain/Painless

2. Intra Oral Examination

a. Oral Mucosa :
b. Tongue :
c. Gums :
 d. Mouth Cleanness Index
Debris Index Calculus Index CPTIN

OHI-S Score :
OHI-S Criteria :

e. Odontogram

Notes:
― : Un-erupted tooth  : Tooth not stable ○ : Caries
X : Missing/Extracted V: Tooth Radix ● : Filling

Date of Data : ……………….. DMF-T :

Signature : ……………….. Def-t :
PTI :

Tooth Inspection Thermis Sondasi Percussion Mobility Diagnose

Resgistration Number : Age :
Patient Name : Alamat :

TREATMENT

No DATE DIAGNOSE TREATMENT MENTOR SIGNATUR