PA DOH School Dental Health Record

H514.027 (02/2013)

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 HOME ADDRESS

FIRST

MIDDLE

GRADE

SEX

M

F

TELEPHONE NO.

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 SRQPONML K

UPPER LOWER

First Exam

Upper Lower

UPPER LOWER

Second Upper Exam Lower

UPPER LOWER

Third Exam

Upper Lower

UPPER LOWER

Fourth Upper Exam Lower

UPPER LOWER

Fifth Exam

Upper Lower

DATE 1ST EXAM 2ND EXAM 3RD EXAM 4TH EXAM 5TH EXAM OTHER

STUDENT REFERRAL EXAMINED OR EVALUATED BY

REFERRED TO

UPPER LOWER

REMARKS (if yes, next page) Yes No Yes No Yes No Yes No Yes No Yes No

NAME OF STUDENT ______________________________________________ DENTAL FINDINGS ? Check Applicable Items

GRADE DATE

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

EXAMINED OR

EVALUATED BY

PROPHYLAXIS

SPECIAL PROJECTS (Specify)

FLUORIDE

Tablet

Mouth Rinse

Oral Evaluation

Passed/ Referred

TOTALS

Def OHI DMF Index

TOOTH BRUSH INSTRUCTIONS

NUTRITION COUNSELING

REMARKS: DATE

DATE

DATE

DATE

DATE

DATE

DATE

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