Dental Clinic Management System
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Individual Dental Patient Record
Personal Information
Surname:
First Name:
Middle Initial:
File No.:
Date of Birth:
Sex:
Male
Female
City:
Province:
Hospital:
Patient Type:
In-Patient
Out-Patient
Category:
Pre-school
School Children
Prenatal
Adult
Address:
Occupation:
Legend (Condition & Treatment)
Condition
Permanent
Tooth Condition
Temporary
✔
Sound/Sealed
✔
D
Decayed
d
F
Filled
f
M
Missing
m
DX
Indicated for Extraction
dx
Un
Unerupted
un
S
Supernumerary Tooth
s
JC
Jacket Crown
jc
P
Pontic
p
Treatment
FV
Fluoride Varnish
FG
Fluoride Gel
PFS
Pit and Fissure Sealant
PF
Permanent Filling
TF
Temporary Filling
X
Extraction
O
Others
Dental Chart
Upper Teeth (Operation | Treatment)
55
54
53
52
51
61
62
63
64
65
Lower Teeth (Operation | Treatment)
85
84
83
82
81
71
72
73
74
75
Permanent Lower Teeth (Operation | Treatment)
48
47
46
45
44
43
42
41
31
32
33
34
35
36
37
38
Permanent Upper Teeth (Operation | Treatment)
18
17
16
15
14
13
12
11
21
22
23
24
25
26
27
28
Dental Examination Summary
Date of Examination:
Age Last Birthday:
Presence of Dental Caries:
Yes
No
Presence of Gingivitis:
Yes
No
Presence of Periodontal Pocket:
Yes
No
Presence of Oral Debris:
Yes
No
Presence of Calculus:
Yes
No
Presence of Neoplasm:
Yes
No
Presence of Dento-Facial Anomaly:
Yes
No
Tooth Count / DMF Index
No. of Teeth Present:
Caries Indicated for Filling:
Caries Indicated for Extraction:
Root Fragment:
Missing Due to Caries:
Filled or Restored:
Total DMF Teeth:
Fluoride & Examiner
Fluoride Application:
Yes
No
Examiner:
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