Oral Health Assessment Form PDF Details

Are you a dentist or healthcare provider looking for an easy way to assess your patient’s oral health? An oral health assessment form is a great tool that enables dental professionals to quickly and accurately track their patient’s overall mouth health. This type of form can be used in both diagnosis and disease management, as well as in educational settings. In this blog post, we will explore the purpose of an oral health assessment form, its components, how it should be completed, and ways it can benefit both patient care providers and patients alike.

QuestionAnswer
Form NameOral Health Assessment Form
Form Length1 pages
Fillable?No
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:

 

 

 

 

 

 

 

Address:

 

 

 

 

Apt.:

 

 

 

 

 

 

 

City:

 

 

 

 

ZIP code:

 

 

 

 

 

School Name:

Teacher:

 

Grade:

Child’s Sex:

 

 

 

 

 

□ Male

□ Female

Parent/Guardian Name:

Child’s race/ethnicity:

 

 

 

 

 

 

□ White □ Black/African American

□ Hispanic/Latino

□ Asian

 

□ Native American

□ Multi-racial

□ Other___________

 

□ 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

□ 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

 

Date

 

 

 

 

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

Date

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.

REVISED – MARCH 2010

How to Edit Oral Health Assessment Form Online for Free

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It is actually straightforward to fill out the form using this detailed tutorial! Here's what you have to do:

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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