Physical Examination Form
Dental Examination Report
CHILD’S NAME: ______________________________________________________ SEX: _____ BIRTH DATE: _____/_____/____ AGE:________
PARENT(S) NAME: ____________________________________________________________ PHONE NUMBER: ____________________________
INSURANCE NUMBER (MEDICAID OR PRIVATE INSURANCE): ________________________________________
HEAD START SITE: ____________________________________________________________________________________
Diagnostic and Preventive Procedures Performed:
|( |Clinical Examination |( |Prophylaxis |( Other | |
|( |X-Rays |( |Fluoride application | | |
Current Status:
|Cavities: | |(How Many) | |Recurrent decay around old fillings: | |(How Many) |
| |
|Gums and supporting tissues: |( Normal & Healthy |( Slight Inflammation (gingivitis) |
| |( Moderate Inflammation (gingivitis) |( Advanced disease (periodontitis) |
| |Other: ______________________________________________________ |
Recommendation: (One selection is required)
|( |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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St. Louis Public Schools
Early Childhood/Early Childhood Special Education
801 N. 11th Street, St. Louis, MO 63101
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|Tooth # or letter |Description of Dental Services Required |
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