PA DOH School Dental Health Record

HL514.47 (rev. 2/24)

COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF HEALTH

SCHOOL DENTAL HEALTH RECORD

Complete the following section before the examination/screen: SCHOOL DISTRICT/CHARTER SCHOOL

COUNTY DATE OF BIRTH

STUDENT: LAST HOME ADDRESS

FIRST

MIDDLE

GRADE TELEPHONE NO.

SEX M F

UPPER LOWER

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

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16

ABCDE FGH I J

32 31 30 29 28 27 26 25 24 23 22 21 20 19 18 17 T SRQPONMLK

UPPER LOWER

First Exam or Screen

Upper Lower

UPPER LOWER

Second Exam or Screen

Upper Lower

Third Exam or Screen

Upper Lower

UPPER LOWER UPPER LOWER

Fourth Exam or Screen

Upper Lower

UPPER LOWER

Fifth Exam or Screen

Upper Lower

Untreated Decay: Treated Decay: Any Sealants on Permanent Molars: Treatment Urgency:

No No No None

Yes Yes Yes Early

UPPER LOWER

Urgent

Name of Dental Provider____________________________ Signature_________________________________ Address____________________________________________________________ Phone ___________________

GRADE DAT E EXAMINED or SCREENED BY PROPHYLAXIS SPECIAL PROJECT S (Specify) VARNISH NUTRITION COUNSELING PREMOLARS 1ST MOLARS 2ND MOLARS TOOTH BRUSH INSTRUCTIONS Oral Evaluation Passed / Referred

HL514.47 (rev. 2/24)

STUDENT REFERRAL

DATE

EXAMINED or SCREENED BY

1ST EXAM or SCREEN

2ND EXAM or SCREEN 3RD EXAM or SCREEN 4TH EXAM or SCREEN 5TH EXAM or SCREEN

DENTAL FINDINGS ? Check Applicable Items

FLUORIDE

K 1 2 3 4 5 6 7 8 9 10 11 12 Other

DATE

DATE

DATE

DATE

Remarks

REFERRED TO

REMARKS (if yes, provide details at bottom of

page)

Yes No

Yes No Yes No Yes No Yes No

SEALANTS

TOTALS

Def OHI DMF Index

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