Private Dental Exam - Department of Health Home
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF HEALTH
PRIVATE DENTIST REPORT
OF DENTAL EXAMINATION OF A PUPIL OF SCHOOL AGE
NAME OF SCHOOL ____________________________________________ DATE __________________ 20 ___
| | | | | |
|NAME OF STUDENT |AGE |SEX |GRADE |SECTION/ROOM |
| | | | | |
|_________________________________________________ | | | | |
|Last First | |M F | | |
|Middle | | | | |
| |
|ADDRESS |
| |
|______________________________________________________________________________________________ |
|No. and Street City or Post Office Borough/Township County State Zip |
| |
|REPORT OF EXAMINATION |
| |TOOTH CHART | |
| | | | |
| |RIGHT |LEFT | |
UPPER |1 |2 |3 |4
A |5
B |6C |7
D |8
E |9
F |10
G |11
H |12
I |13J |14 |15 |16 |
Upper | |
LOWER |32 |31 |30 |29
T |28
S |27
R |26
Q |25
P |24
O |23
N |22
M |21
L |20
K |19 |18 |17 |
Lower | |EXAM |
UPPER | | | | | | | | | | | | | | | | |
Upper | | |
LOWER | | | | | | | | | | | | | | | | |
Lower | |
Is the student under treatment Yes No
Treatment completed Yes No
__________________________________________
Date of Dental Examination
__________________________________________ __________________________________________
Signature of Dental Examiner Print Name of Dental Examiner
__________________________________________
Address of Dental Examiner
................
................
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