Form Ioci 0600-10 - Proof Of School Dental Examination, Formulario Comprobante Del Examen Dental Escolar Page 2

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Estado de Illinois
Departamento de Salud Pública
FORMULARIO COMPROBANTE DEL EXAMEN DENTAL ESCOLAR
Para ser completado por el padre/madre (por favor impresión):
Nombre del Estudiante:
Apellido
Nombre
Inicial
Fecha de Nacimiento:
/
/
(Mes/Día/Año)
Dirección:
Calle
Ciudad
Código Postal
Número de Teléfono:
Nombre de la Escuela:
Grado:
Sexo:
Masculino
Femenino
Nombre del padre/madre o encargado:
Dirección del padre/madre o encargado:
To be completed by dentist: (Para ser completado por el dentista:)
Oral Health Status (check all that apply)
Yes
No Dental Sealants Present
Yes
No Caries Experience / Restoration History —
A filling (temporary/permanent) OR a tooth that is missing because it was
extracted as a result of caries OR missing permanent 1
molars.
st
Yes
No Untreated Caries —
At least 1/2 mm of tooth structure loss at the enamel surface. Brown to dark-brown coloration of the
walls of the lesion. These criteria apply to pit and fissure cavitated lesions as well as those on smooth tooth surfaces. If retained
root, assume that the whole tooth was destroyed by caries. Broken or chipped teeth, plus teeth with temporary fillings, are consid-
ered sound unless a cavitated lesion is also present.
Yes
No Soft Tissue Pathology
No Malocclusion
Yes
Treatment Needs (check all that apply)
Urgent Treatment —
abscess, nerve exposure, advanced disease state, signs or symptoms that include pain, infection, or swelling
Restorative Care —
amalgams, composites, crowns, etc.
Preventive Care —
sealants, fluoride treatment, prophylaxis
Other —
periodontal, orthodontic
Please note____________________________________________________________________________________
Signature of Dentist _________________________________________
Date of Exam ____________________
Address ___________________________________________________
Telephone _______________________
Street
City
ZIP Code
Departamento de Salud Pública de Illinois, División de la Salud Oral
217-785-4899 • TTY (sólo para personas con impedimento auditivo) 800-547-0466 •
Impreso con Autoridad del Estado de Illinois
IOCI 0600-10

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