Student Dental Health Record
Student Name
Grade/Section
Date of Birth
Gender
Male
Female
Other
Student ID
Date of Exam
Parent/Guardian Name
Contact Number
Dental History
Previous Dental Visits?
Yes
No
If Yes, Date of Last Visit
Reason for Last Visit
Any dental pain/complaints?
Yes
No
If Yes, describe
Clinical Findings
Teeth Present
Cavities Observed
Missing/Extracted Teeth
Gum Condition
Malocclusion
Other Findings
Oral Hygiene Assessment
Brushing Frequency (per day)
Type of Toothbrush Used
Uses Fluoride Toothpaste?
Yes
No
Unsure
Other Oral Hygiene Practices
Dentist's Recommendations
Dentist's Name
Signature
Date