Child'S Dental Examination Form printable pdf download

Child'S Dental Examination Form

The Salvation Army Children's Services

425 Allentown Drive, Suite 1

Allentown, PA 18109

(610) 821-7706

Dental Examination Form

Patient’s Name: __________________________________________________________

Dentist’s Name: __________________________________________________________

Dentist’s Address: ________________________________________________________

Date of Examination: ______________________________________________________

_____ Initial Examination

_____ Follow-up Examination

Dental History:

_____ Routine Check-ups

_____ Specialists

_____ Has Never Seen Dentist

_____ Dental Emergencies Only

X-rays for diagnostic purposes deemed necessary _______________________________

Restored Teeth (#1-32 or A-T) ______________________________________________

Missing Teeth (#1-32 or A-T) _______________________________________________

Are missing teeth adequately replaced or space maintainers inserted?

_____ YES

_____ NO

Has the child ever had problems with previous dental treatment?

_____ YES

_____ NO

Has the child had adequate dental treatment in the past?

_____ YES

_____ NO

Hygiene:

_____ Excellent

_____ Good

_____ Poor

PLEASE FILL OUT BOTH SIDES AND SIGN AT THE BOTTOM OF THE BACK PAGE

Child'S Dental Examination Form