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PEMERINTAH KABUPATEN BANYUWANGI

DINAS KESEHATAN
UPTD. PUSKESMAS TAMPO
Jln. Purwoharjo No.130 Telp. 0333-396905 Cluring – Banyuwangi 68482
e-mail : puskesmastampo@yahoo.co.id

No. Rekam Medis


FORMULIR PEMERIKSAAN ODONTOGRAM

NAMA :
UMUR :
JENIS KELAMIN :
ALAMAT :

TMJ : .........................................................................
Tonsil : .........................................................................
Bibir : .........................................................................
Lidah : .........................................................................
Palatum : .........................................................................
Diastema :.........................................................................
Gusi : .........................................................................
Mukosa mulut :.........................................................................
Lain-lain : .........................................................................

Ro foto : .......................................................................

Tanggal :..........................................................Gambaran

Radiografis : ............................................................................................................................. Gigi

Status Klinis Diagnosa Treatment Planning

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