California Department of Education
March 2008
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
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.