Child'S Dental Examination Form (Page 2 of 2) in pdf

Child'S Dental Examination Form Page 2

Within Normal Limits

Pathology

Lips

__________________

Labial & Buccal Vestibules __________________

__________________

Gingiva

__________________

Floor of Mouth

__________________

Tongue

__________________

Oral Pharynx

__________________

Alveolus

__________________

Salivary Glands

__________________

Occlusion

__________________

Not Present

Present (explain)

Facial Abnormalities

__________________

Lymphadenopathy

__________________

Carious Teeth (#1-32 or A-T) ________________________________________________

Extractions Necessary (#1-32 or A-T)

____________________________________

Periapical Pathology (#1-32 or A-T) __________________________________________

All Necessary Work Completed ________________________________________ (Date)

Six (6) Month Check-up Due __________________________________________ (Date)

Dentist’s Name (please print) _______________________________________________

Dentist’s Signature ________________________________________________________

Date _____________________________________

Child'S Dental Examination Form Page 2