Oral Health Assessment Form
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1Oral Health Assessment Form
T07-003, English, Arial Font
Page 1 of 1
Oral Health Assessment Form
California law (Education Code Section 49452.8) states your child must have a dental check-up by May 31 of his/her first
year in public school. A California licensed dental professional operating within his scope of practice must perform the
check-up and fill out Section 2 of this form. If your child had a dental check-up in the 12 months before he/she started
school, ask your dentist to fill out Section 2. If you are unable to get a dental check-up for your child, fill out Section 3.
Section 1: Child’s Information (Filled out by parent or guardian)
Child’s First Name:
Last Name:
Middle Initial:
Child’s birth date:
Address:
Apt.:
City:
ZIP code:
School Name:
Teacher:
Grade:
Child’s Sex:
□ Male
□ Female
Parent/Guardian Name:
Child’s race/ethnicity:
□ White
□ Black/African American
□ Hispanic/Latino
□ Asian
□ Native American
□ Multi-racial
□ Other___________
□ Native Hawaiian/Pacific Islander
□ Unknown
Section 2: Oral Health Data Collection (Filled out by a California licensed dental professional)
IMPORTANT NOTE: Consider each box separately. Mark each box.
Assessment
Caries Experience
Visible Decay
Treatment Urgency:
Date:
(Visible decay and/or
Present:
□ No obvious problem found
fillings present)
□ Early dental care recommended
(caries without pain or infection;
or child would benefit from sealants or further evaluation)
□ Yes
□ No
□ Yes
□ No
□ Urgent care needed
(pain, infection, swelling or soft tissue lesions)
Licensed Dental Professional Signature
CA License Number
Date
Section 3: Waiver of Oral Health Assessment Requirement
To be filled out by parent or guardian asking to be excused from this requirement
Please excuse my child from the dental check-up because: (Check the box that best describes the reason)
□ I am unable to find a dental office that will take my child’s dental insurance plan.
My child’s dental insurance plan is:
□ Medi-Cal/Denti-Cal
□ Healthy Families
□ Healthy Kids
□ Other ___________________
□ None
□ I cannot afford a dental check-up for my child.
□ I do not want my child to receive a dental check-up.
Optional: other reasons my child could not get a dental check-up:
If asking to be excused from this requirement:
____________________________________________________
Signature of parent or guardian
Date
The law states schools must keep student health information private. Your child's name will not be part of any report as a
result of this law. This information may only be used for purposes related to your child's health. If you have questions,
please call your school.
Return this form to the school no later than May 31 of your child’s first school year.
Original to be kept in child’s school record.
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