Dental Form - Dayton Public Schools

ADVERTISEMENT

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: ________________

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Medical
Go