Ill. Admin. Code tit. 77, pt. 665, subpt. F, app D
Illinois Department of Public Health
PROOF OF SCHOOL DENTAL EXAMINATION FORM
To be completed by the parent (please print):
Student's Name: LastFirstMiddle | Birth Date: | (Month/Day/Year) / / | |
Address: StreetCityZIP Code | Telephone: | ||
Name of School: | Grade Level: | Gender: MaleFemale | |
Parent or Guardian: | Address (of parent/guardian): | ||
To be completed by dentist:
Oral Health Status (check all that apply)
[] Yes[] No | Dental Sealants Present | |||
[] Yes[] No | Caries Experience / Restoration History- A filling (temporary or permanent) OR a tooth that is missing because it was extracted as a result of caries OR missing permanent 1st molars. Include both treated and untreated decay. | |||
[] Yes[] No | Untreated Caries - At least 1/2 mm of tooth structure loss at the enamel surface. Brown to dark-brown coloration of the walls of the lesion. These criteria apply to pit and fissure cavitated lesions as well as those on smooth tooth surfaces. If retained root, assume that the whole tooth was destroyed by caries. Broken or chipped teeth, plus teeth with temporary fillings, are considered sound unless a cavitated lesion is also present. | |||
[] Yes[] No | Soft Tissue Pathology | |||
[] Yes[] No | Malocclusion | |||
Treatment Needs (check all that apply)
[] | Urgent Treatment -abscess, nerve exposure, advanced disease state, signs or symptoms that include pain, infection or swelling |
[] | Restorative Care- amalgams, composites, crowns, etc. |
[] | Preventive Care -sealants, fluoride treatment, prophylaxis |
[] | Other- periodontal, orthodontic |
[] | Please note |
Signature of Dentist | _______________________ | Date of Exam | __________________ |
Address: | Telephone | _____________________ | |||||
Street | _______________________ | City | ______________ | Zip Code | ______________ | ||
Ill. Admin. Code tit. 77, pt. 665, subpt. F, app D