Form Examination – Fill Out and Use This PDF

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Form Examination PDF Details

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Question	Answer
Form Name	Form Examination
Form Length	1 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	15 sec
Other names	school dental exam, dental exam, school form illinois, illinois school dental form 2021

Form Preview Example

STATE OF ILLINOIS

Illinois Department of Public Health

PROOF OF SCHOOL DENTAL EXAMINATION FORM

To be completed by the parent (please print):

Student’sName:	Last	First	Middle	BirthDate: (Month/Day/Year)
				/	/

Address:	Street	City	ZIPCode	Telephone:

NameofSchool:			GradeLevel:	Gender:
				Male	Female

ParentorGuardian:			Address(ofparent/guardian):

To be completed by dentist:

OralHealthStatus(checkallthatapply)

Yes No DentalSealantsPresent

Yes	No	CariesExperience/RestorationHistory — Afilling (temporary/permanent) OR a tooth that is missing because it was
		extracted as a result of caries OR missing permanent 1st molars.
Yes	No	UntreatedCaries — At least 1/2 mm of tooth structure loss at the enamel surface. Brown to dark-brown coloration of the
		walls of the lesion. These criteria apply to pit and fissure cavitated lesions as well as those on smooth tooth surfaces. If retained
		root, assume that the whole tooth was destroyed by caries. Broken or chipped teeth, plus teeth with temporary fillings, are consid-
		ered sound unless a cavitated lesion is also present.

Yes No SoftTissuePathology

Yes No Malocclusion

TreatmentNeeds(checkallthatapply)

UrgentTreatment —abscess, nerve exposure, advanced disease state, signs or symptoms that include pain, infection, or swelling

RestorativeCare — amalgams, composites, crowns, etc.

PreventiveCare —sealants, fluoride treatment, prophylaxis

Other — periodontal, orthodontic

Please note____________________________________________________________________________________

SignatureofDentist	_________________________________________		DateofExam ____________________
Address ___________________________________________________			Telephone _______________________
Street	City	ZIPCode
	IllinoisDepartmentofPublicHealth,DivisionofOralHealth
217-785-4899 • TTY(hearingimpaireduseonly)800-547-0466 • www.idph.state.il.us
IOCI 0600-10		PrintedbyAuthorityoftheStateofIllinois

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Form Examination – Fill Out and Use This PDF

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