formulir penilaian ohi-s

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FORMULIR PENILAIAN OHI-S Tgl. Pemeriksaan : .......................................... Nama Pemeriksa: ......................................... Puskesmas / BPG / Sekolah : ......................... Kab / Kecamatan :........................................ Nama Pasien: .................................................. Jenis Kelamin: ......................................... Umur : ....................................................... ... DEBRIS INDEX KALKULUS INDEX SKOR : SKOR : OHI-S : FORMULIR PENILAIAN OHI-S Tgl. Pemeriksaan : .......................................... Nama Pemeriksa: ......................................... Puskesmas / BPG / Sekolah : ........................ Kab / Kecamatan :........................................ Nama Pasien: .................................................. Jenis Kelamin: ......................................... Umur : ....................................................... .. - - - -

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formulir penilaian OHI-S

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FORMULIR PENILAIAN OHI-STgl. Pemeriksaan : .......................................... Nama Pemeriksa: .........................................Puskesmas / BPG / Sekolah : ......................... Kab / Kecamatan :........................................Nama Pasien: .................................................. Jenis Kelamin: .........................................Umur: ..........................................................

DEBRIS INDEXKALKULUS INDEX-

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SKOR : SKOR :

OHI-S :FORMULIR PENILAIAN OHI-STgl. Pemeriksaan : .......................................... Nama Pemeriksa: .........................................Puskesmas / BPG / Sekolah : ........................ Kab / Kecamatan :........................................Nama Pasien: .................................................. Jenis Kelamin: .........................................Umur: .........................................................

DEBRIS INDEXKALKULUS INDEX-

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SKOR : SKOR :

OHI-S :