A.UMUM
1. MURID 2. ORANG TUA
Nama : ................................................. Nama : .................................
Jenis Kelamin : ................................................. Pendidikan
Tanggal lahir : ................................................. Ayah : TS/SD/SMP/SMA/AK/PT
Alamat : ................................................. Ibu : TS/SD/SMP/SMA/AK/PT
Pekerjaan
Ayah : .................................
Ibu : .................................
B. KHUSUS
1. KEBERSIHAN MULUT
6 1 6 6 1 6
6 1 6 6 1 6
Debris skor : .....................
Kalkulus skor : .................
2. KARIES GIGI
a. GIGI SULUNG
Jumlah Gigi Sulung yang ada = .....................
d = ..........................
5 5 5 5 5 6 6 6 6 6
5 4 3 2 1 1 2 3 4 5 m = ..........................
8 8 8 8 8 7 7 7 7 7 f = .......................... +
Jumlah d m f = ..........................
b. GIGI TETAP
Jumlah Gigi Tetap yang erupsi = …………..
D = ……………….
1 1 1 1 1 1 1 1 2 2 2 2 2 2 2 2
8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8 M = ……………….
4 4 4 4 4 4 4 4 3 3 3 3 3 3 3 3 F = ………………. +
8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8
5. MENYIKAT GIGI
b. Waktu :
No Elemen Diagnosis Treatment planning