Oral Health Assessment Form PDF Details

Maintaining the oral health of children is a critical aspect of their overall well-being and educational readiness. In California, the Oral Health Assessment form serves as a bridge between public education and healthcare, ensuring that children entering public school are evaluated for dental issues that could impair their learning and general health. Under Education Code Section 49452.8, it is mandated that this assessment be completed by May 31 of the student's first school year. This comprehensive form is divided into sections that request detailed information from parents or guardians, as well as diagnostic data from a California licensed dental professional. Parents provide basic information and background about their child, including their name, birth date, and demographic details. Dental professionals are then tasked with recording the presence of caries, fillings, and determining the urgency of any needed dental care. Furthermore, the form offers a waiver section for parents unable to meet this requirement, due to reasons such as inability to afford dental care or lack of insurance acceptance. The aim of including such diverse data is to foster a proactive approach to oral health among young children, while remaining sensitive to the varying circumstances families may face. Notably, the document emphasizes privacy and confidentiality, ensuring that personal health information is protected and used solely for the benefit of the child's health. This form not only highlights California's commitment to children's oral health but also recognizes the profound connection between health and education, emphasizing the need for early detection and treatment of dental issues.

Form NameOral Health Assessment Form
Form Length1 pages
Fillable fields0
Avg. time to fill out15 sec
Other namescalifornia oral health assessment form, california oral assessment form, oral health assessment form pdf, ca oral form

Form Preview Example

Visible Decay Treatment Urgency: Present:No obvious problem found
Early dental care recommended

January 2007 Keep this with your child’s immunization record (yellow card)! Calif Dept. of Education

Oral Health Assessment Form

California law (Education Code Section 49452.8) states your child must have a dental check-up by May 31 of his/her first year in public school. A California licensed dental professional operating within their scope of practice must perform the check-up and fill out Section 2 of this form. If your child had a dental check-up in the 12 months before he/she started school, ask your dentist to fill out Section 2. If you are unable to get a dental check-up for your child, fill out Section 3.

Section 1: Child’s Information (Filled out by parent or guardian)

Child’s First Name:

Last Name:


Middle Initial:

Child’s birth date:


























ZIP code:






School Name:




Child’s Sex:








Parent/Guardian Name:

Child’s race/ethnicity:







White Black/African American




Native American




Native Hawaiian/Pacific Islander Unknown



Section 2: Oral Health Data Collection (Filled out by a California licensed dental professional)

IMPORTANT NOTE: Consider each box separately. Mark each box.

Assessment Date:

Caries Experience

(fillings present)



Yes No

(Caries without pain or infection

or child would benefit from sealants or further evaluation)

Urgent care needed (pain, infection, swelling or soft tissue lesions)

Licensed Dental Professional Signature

CA License Number







PRINTED Provider Name/Clinic Name

Phone #


Fax #

Section 3: Waiver of Oral Health Assessment Requirement

To be filled out by parent or guardian asking to be excused from this requirement

Please excuse my child from the dental check-up because: (Check the box that best describes the reason)

I am unable to find a dental office that will take my child’s dental insurance plan. My child’s dental insurance plan is:

Medi-Cal/Denti-Cal Healthy Families Healthy Kids Other ___________________ None

I cannot afford a dental check-up for my child.

I do not want my child to receive a dental check-up.

Other reasons my child did not get a dental check-up:

If asking to be excused from this requirement: ____________________________________________________

Signature of parent or guardian


The law states schools must keep student health information private. Your child's name will not be part of any report as a result of this law. This information may only be used for purposes related to your child's health. If you have questions, please call your school.

Return this form to the school no later than May 31 of your child’s first school year.

Original to be kept in child’s school record.


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1. You'll want to fill out the oral health assessment form 2021 accurately, therefore be mindful when filling out the areas containing these particular fields:

The right way to fill in oral health form stage 1

2. Right after performing this part, head on to the next step and enter the necessary particulars in these blanks - Licensed Dental Professional, Date, PRINTED Provider NameClinic Name, Section Waiver of Oral Health, Please excuse my child from the, I am unable to find a dental, If asking to be excused from this, Signature of parent or guardian, Date, The law states schools must keep, Return this form to the school no, and Revised March.

oral health form completion process clarified (step 2)

Concerning Section Waiver of Oral Health and Date, make sure you don't make any errors in this section. Those two could be the most important fields in this document.

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