The bridge between early childhood education and healthcare is often manifested in the form of essential forms and documentation, a prime example being the Form 604 551 – a crucial document for children enrolled in the Head Start and State Preschool programs. This dental exam form plays a vital role in ensuring that young learners receive the necessary dental care and preventative treatment from an early stage. Designed not just as a routine check-up record, the form encompasses several key sections including the child's personal information, consent and details of the guardian, specifics about the dental exam administered, and the resultant findings. Dentists and dental care providers are required to fill out the form detailing the services provided, any diagnoses made, and subsequent treatments initiated if necessary. Importantly, it also schedules future dental visits, thereby setting a framework for ongoing dental health monitoring. Unique to this form is its dual-use, serving not only as a health record but also as a communication tool between health care providers and Head Start staff to ensure that children's nutritional and other follow-up needs are addressed. By embedding such structured healthcare follow-ups within educational programs, the Form 604 551 underscores the interconnectedness of health and education in fostering well-rounded development in children. It epitomizes a proactive approach to pediatric health care, emphasizing preemptive care and regular check-ups to head off potential dental issues that can impact both the academic and personal growth of children enrolled in these foundational programs.
| Question | Answer |
|---|---|
| Form Name | Form 604 551 |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | 2012, Caries, 1ST, head start dental exam form |
Head Start - State Preschool
DENTAL EXAM FORM
PROGRAM CHILD IS ENROLLED IN
Head Start |
Early Head Start |
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Center Base |
Home Base |
FCC |
LAST NAME, FIRST NAME, MIDDLE INITIAL OF CHILD
SEX
M
F
DATE OF BIRTH
NAME OF PARENT OR GUARDIAN
DELEGATE AGENCY NAME/SITE
TO BE COMPLETED BY DENTIST
(THIS IS NOT A BILLING FORM)
DENTAL EXAMINATION ADMINISTERED BY (TYPE OR PRINT NAME)
SIGNATURETELEPHONE NUMBER
ADDRESS
DENTAL SERVICES PROVIDED
Dental Examination
Yes
No |
Date of Exam |
Preventive Dental Care Provided (including Fluoride &/or Anticipatory Guidance)
Yes
No
DESCRIBE PREVENTIVE CARE
DENTAL DIAGNOSIS
Normal Examination/No Treatment Needed Dental Treatment Needed
Dental Diagnosis: |
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Cavities |
Number of Cavities |
Other Diagnosis
Early Childhood Caries (ECC)
DENTAL TREATMENT
Dental Treatment Initiated |
Yes |
No |
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Describe Dental Treatment |
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Has all Dental Treatment Been Completed? |
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Yes |
No |
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Date of Next Visit for Treatment |
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NEXT DENTAL EXAMINATION |
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Date Next Routine Dental Examination Due |
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TO BE COMPLETED BY HEAD START STAFF |
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SIGNATURE OF STAFF COMPLETING 1ST REVIEW |
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POSITION |
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DATE |
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SIGNATURE OF STAFF COMPLETING 2ND REVIEW |
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POSITION |
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DATE |
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HEAD START |
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REFERRED FOR
Nutrition
Other
INITIALS/DATE FORM RECEIVED
FORM NO.