District Of Columbia Oral Health (Dental Provider) Assessment Form
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1
2CONFIDENTIAL FORM- SIDE ONE
Please review instruction on side two prior to completing form
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Part 1. Child’s Personal Information
Child’s Last Name
Child’s First & Middle Name
Date of Birth
Gender:
School or Child Care facility:
M
F
Parent/Guardian Name
Telephone1:
Home
Cell
Work
Home Address:
Ward
Emergency Contact:
Telephone2:
Home
Cell
Work
City/State (if other than D.C.)
Zip code:
Race/Ethnicity:
White Non Hispanic
Black Non Hispanic
Hispanic
Asian or Pacific Islander
Other_________________
Primary Care Provider (Medical):
Dentist/Dental Provider:
Medicaid
Private Insurance
None
Other ________________________________
Part 2. Child’s Clinical Examination
Date of Exam __________________________
(to be completed by the Dental Provider)
(Please use key to document all findings on line next to each tooth)
Tooth #
Tooth #
Tooth #
Tooth #
1 _______
17 ______
A ______
K ______
2 _______
18 ______
B ______
L ______
Key (Check Appropriate)
3 _______
19 ______
C ______
M ______
S - Sealants
X - Missing teeth
4 _______
20 ______
D ______
N ______
5 _______
21 ______
E ______
O ______
Restoration
Non-restorable/ Extraction
6 _______
22 ______
F ______
P ______
1D-One surface decay
UE- Unerupted Tooth
7 _______
23 ______
G ______
Q ______
2D-Two surface decay
8 _______
24 ______
H ______
R ______
3D-Three surface decay
9 _______
25 ______
I ______
S ______
4D-More than three surface decay
10 ______
26 ______
J ______
T ______
11 ______
27 ______
12 ______
28 ______
13 ______
29 ______
14 ______
30 ______
15 ______
31 ______
16 ______
32 ______
Part 3. Clinical Findings and Recommendations (Please indicate in Finding column)
Findings
Comments
1. Gingival Inflammation
Y
N
2. Plaque and/or Calculus
Y
N
3. Abnormal Gingival Attachments
Y
N
4. Malocclusion
Y
N
5. Other (e.g. cleft lip/palate)
Preventive services completed
Yes
No
Part 4. Final Evaluation/Required Dental Provider Signatures
This child has been appropriately examined. Treatment
is complete.
is incomplete. Referred to ______________________
DDS/DMD Signature
Print Name
Date
Address
Fax
Phone
Part 5. Required Parent/Guardian Signatures
Parent or Guardian Release of Health Information.
I give permission to the signing health examiner or facility to share the health information on this form with my child’s school, childcare, camp, or Department of
Health
PRINT NAME of parent or guardian
SIGNATURE of parent or guardian
Date
nd
Top Copy- School Nurse/DC Oral Health Program
2
Copy- Oral Health Provider
Forms are available online at
5/24/04
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