No. :

Tanggal :

STATUS GIGI ANAK

Nama / Panggilan :............................................/.................................................Jenis Kelamin : L / PUmur : ..............................................................................................Alamat : ..............................................................................................Telp. : ..............................................................................................Nama Orang Tua : ……………………………………………………………..Pekerjaan Orang Tua : ……………………………………………………………..Odontogram:

Keadaan Gigi:Gigi Berlubang/ Decay (d) : ....................................................Gigi Tanggal Prematur dan Indikasi Pencabutan / Exsfoliated (e) : ....................................................Gigi Tumpatan / Filled (f) : ....................................................

Keterangan : Pulpitis Reversible....................................................................................: Pulpitis Ireversible ………………...……………………………………: Periodontitis Kronis................................………………………………..

Perlu Perawatan : YA / Tidak