115 S. Ludlow St. Dayton, Ohio 45402
Telephone: 937-542-3205 Fax: 937-542-3204
Dayton Public Schools Preschool Program
Title 1 ECE, ECIP, Montessori
Dental Form
Exam Date: ___/___/____ Child’s Name: _________________________________ Birth date: ______________
School: _______________________________
Exam Completed by: DMD
RDH
Other: Specify ___________________________________________
Provider Setting:
Doctor/Dentist/Clinic
School/Center
Other: Specify ________________________
Evaluation Type:
Screening
Exam
Flossing Frequency:
Daily
Weekly
Occasionally
Never
Number of Times per Day Child Brushes Teeth:
______
Uses Fluoride Toothpaste:
Yes No
Takes Fluoride Supplement: Yes No
Gum Condition:
Normal
Swollen
Bleeds Easily
Infected
General Comments on Oral Health: ________________________________________________________
Today’s Visit:
Treatment:
No Needs
Visual Screening
Treatment Needed
Full Exam
X-Rays
Next Appointment Date:
Cleaning
______/______/______
Fluoride Treatment
Oral Hygiene Instruction
Treatment Plan:
Treatment (specify)
________________________
________________________
________________________
________________________
________________________
________________________
________________________
________________________
________________________
________________________
Provider Signature:
_______________________________ Exam Completion Date: ____/____/_____
Printed or Stamped Name/Address of Provider: _____________________________________________
Address: _________________________________________________
Phone: ________________