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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