Preschool Oral Health Preliminary Exam Form And Prevention Services Page 2

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F-40335 (07/08)
INSTRUCTIONS
1.
The Site is the name of the agency.
2.
The Identification Number i.e., patient record number
3.
For screening information refer to Basic Screening Surveys: An Approach to Monitoring Community Oral health, 1999, ASTDD, for
completing the PARTICIPANT INFORMATION section of the form.
4.
For caries risk assessment refer to Integrating Preventive Oral Health Measures into Healthcare Practice, Wisconsin Department of
Health Services
5.
Address any questions to:
DEPARTMENT OF HEALTH SERVICES
Division of Public Health
State Dental Hygiene Officer
1 West Wilson Street, Room 250
Madison WI 53702
2

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