Early Childhood Caries Prevention Screening

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DEPARTMENT OF HEALTH SERVICES
STATE OF WISCONSIN
Division of Public Health
F-40303 (Rev. 07/08)
EARLY CHILDHOOD CARIES PREVENTION SCREENING
Participation is voluntary, information collected on this form will be used for tracking treatment, and services provided to the patient and will be used only for this
purpose. See instructions below.
Date of Screening (mm/dd/yyyy)
Site
Initials - Screener
PARTICIPATION INFORMATION
Identification Number
Birth Date (mm/dd/yyyy)
Age
Gender
Race and Ethnicity
5= American Indian/Alaska Native
1=Male
1=White
6=Native Hawaiian/Pacific Islander
2= Female
2=African-American
7=Multi-racial
3=Hispanic
9=Unknown
4=Asian
Untreated Caries
Caries Experience
0=No untreated cavities
0=No caries experience
1=Untreated cavities
1=Caries experience
Early Childhood Caries
Treatment Urgency
0=No ECC
0=No obvious problem
1=ECC present
1=Early dental care
2=Urgent care
Child has Special Health Care Needs
Specify needs (optional):
0=No
1=Yes
Comments
Fluoride Varnish Prescription
Fluoride Varnish Applications
Dosage:
Application Schedule:
.25ml (preschool)
1. Application Date ______Provider Initials_________
.40ml (school aged)
2. Application Date ______Provider Initials_________
3. Application Date ______Provider Initials_________
_______________________________________________________
SIGNATURE – Prescriber
INSTRUCTIONS
1.
The Site is the name of the agency.
2.
The Identification Number i.e., patient record number
3.
Please refer to Basic Screening Surveys: An Approach to Monitoring Community Oral health, 1999, ASTDD, for completing the
PARTICIPANT INFORMATION section of the form.
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

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