Physical Examination Form



Chugachmiut

Head Start Program

1840 Bragaw Street Suite 110

Anchorage, Alaska 99508-3463

(907) 562-4155 Fax (907) 563-2891

Dental Examination Report

CHILD’S NAME: ______________________________________________________ SEX: _____ BIRTH DATE: _____/_____/____ AGE:________

PARENT(S) NAME: ____________________________________________________________ PHONE NUMBER: ____________________________

HEAD START SITE: ____________________________________________________________________________________

Diagnostic and Preventive Procedures Performed:

|( |Clinical Examination |( |Prophylaxis | |

|( |X-Rays |( |Other | |

| | |Othe| | |

| | |r | | |

|( |Fluoride Varnish Application-FV | |Recommended # of FV Applications Per/Yr |( 1 |( 2 ( 3 |

Current Status:

|Cavities: | |(How Many) | |Recurrent decay around old fillings: | |(How Many) |

| |

|Gums and supporting tissues: |( Normal & Healthy |( Slight Inflammation (gingivitis) |

| |( Moderate Inflammation (gingivitis) | |

| |Other: ______________________________________________________ |

Recommendation:

|( |No further treatment recommended at this time. |Return in ______________ months for an examination. |

|( |Additional dental treatment is required. Treatment plan is identified below. |

_________________________________ _________________________________________ ___________

Dentist Name (Please Print) Signature Date

__________________________________________________________________ _____________________

Address, City, State & Zip Code Phone No.

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|Tooth # or letter |Description of Dental Services Required |

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