Proof Of School Dental Examination Form - Illinois Department Of Public Health

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Illinois Department of Public Health
PROOF OF SCHOOL DENTAL EXAMINATION FORM
To be completed by the parent (please print):
Student’s Name:
Last
First
Middle
Birth Date:
(Month/Day/Year)
/
/
Address:
Street
City
ZIP Code
Telephone:
Name of School:
Grade Level:
Gender:
Male
Female
Parent or Guardian:
Address (of parent/guardian):
To be completed by dentist:
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
No Untreated Caries —
Yes
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
Yes
No Malocclusion
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 ____________________________
Address ___________________________________________________
Telephone _______________________
Street
City
ZIP Code
Illinois Department of Public Health, Division of Oral Health
217-785-4899 • TTY (hearing impaired use only) 800-547-0466 •
Printed by Authority of the State of Illinois
P.O.#346085
5M
10/05

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