File No.
______
___History Of Previous Hospitalization REPUBLIC OF THE PHILLPPINES
DEPARTMENT OF HEALTH
___Medical (Last Admission & Cause) ________________________________ REGIONAL OFFICE____
SILAGO SOUTHERN LEYTE
___Surgical (Post-Operative) _______________________________________ (MUNICIPALITY/CITY/PROVINCE)
___Blood Transfusion (Month & Year) ______________________________ INDIVIDUAL PATIENT TREATMENT RECORD
___Tattoo NAME _________________________________________________________________________
SURNAME FIRST NAME Middle Name
___Others (Please Specify) __________________________________________
DATE OF BIRTH ________________________________________________________________
PLACE OF BIRTH __________________________________________AGE______SEX_________
PATIENTS/ GUARDIANS NAME AND SIGNATURE ADDRESS ________________________________________________________________
DIETARY HABITS/SOCIAL HISTORY OCCUPATION ________________________________________________________________
__SUGAR SWEETENED BEVERAGES/ FOOD (AMOUNT, FREQUENCY & DURATION) __________ PARENT/GUARDIAN ________________________________________________________________
__USE OF ALCOHOL (AMOUNT, FREQUENCY & DURATION) ____________________________
__USE OF TOBACCO (AMOUNT, FREQUENCY & DURATION) ____________________________
OTHER PATIENT INFORMATION (MEMBERSHIP)
__BETELNUT CHEWING (AMOUNT, FREQUENCY & DURATION)
ORAL HEALTH CONDITION ____National Household Targeting System- Poverty Reduction (NHTS -PR)
A. ABSENT (ˎ ̷) IF PRESENT (X) IF ABSENT ____Pantawid Pamilyang Pilipino Program (4p’s)
Date Of Oral Examination ____Indigenous People (IP)
Orally Fit Child (OFC)
____Person With Disabilities (PWD’s)
Dental Caries
____Philhealth (Indicate Number)
Gingivitis
Periodontal Disease ____SSS (Indicate Number) _______________________________________________
Debris ____GSIS (Indicate Number) _______________________________________________
Calculus
Abnormal Growth
VITAL SIGNS
Cleft Lip/ Palate
BLOOD PRESSURE: ____________________ PULSE RATE: _______________________
Others
(Supernumerary, Malocclusions, Etc.) TEMPERATURE: ____________________
B. INDICATE NUMBER
No. Of Perm. Teeth Present MEDICAL HISTORY
No. Of Perm. Sound Teeth
____ALLERGIES (PLEASE SPECIFY) ___________________________________________________
No. Of Decayed Teeth (D)
____HYPERTENSION/CVA
No. Of Missing Teeth (M)
No. Of Filled Teeth (F) ____DIABETES MELLITUS
Total DMF Teeth ____BLOOD DISORDERS
No. Of Temp. Teeth Present ____CARDIOVASCULAR/ HEART DISEASE
No. Of Temp. Sound Teeth ____ THYROID DISORDERS
No. Of Decayed Teeth (D)
____HEPATITIS (PLEASE SPECIFY TYPE) _____________________________________________________
No. Of Filled Teeth(F)
Total Of Teeth ____MALIGNANCY (PLEASE SPECIFY) _____________________________________________________
