School Dental Form
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF HEALTH
SCHOOL DENTAL HEALTH RECORD
Complete the following section before the examination/evaluation:
|SCHOOL DISTRICT COUNTY |DATE OF BIRTH |
|STUDENT: LAST FIRST MIDDLE |GRADE |SEX |
| | |M F |
|HOME ADDRESS TELEPHONE NO. |
| |
| |
|Record on Dental Chart: Deciduous teeth - d (Decayed), e (indicated for extraction), and f (filled) |
|Permanent teeth - D (Decayed), M (Missing), and F (Filled) |
| | | |
| |TOOTH CHART | |
| |RIGHT |LEFT | |
| |
|UPPER |
|DATE |EXAMINED OR EVALUATED BY |REFERRED TO |REMARKS |
| | | |(if yes, next page) |
|1ST EXAM | | |Yes No |
|2ND EXAM | | |Yes No |
|3RD EXAM | | |Yes No |
|4TH EXAM | | |Yes No |
|5TH EXAM | | |Yes No |
|OTHER | | |Yes No |
NAME OF STUDENT ______________________________________________
DENTAL FINDINGS – Check Applicable Items
| | |
|Grade |Date |
|DATE | |
| | |
|DATE | |
| | |
|DATE | |
| | |
|DATE | |
| | |
|DATE | |
| | |
|DATE | |
| | |
................
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