State of Illinois
Illinois Department of Public Health
PROOF OF SCHOOL DENTAL EXAMINATION FORM
Illinois law (Child Health Examination Code, 77 Ill. Adm. Code 665) states all children in kindergarten and the second, sixth and ninth grades of any
public, private or parochial school shall have a dental examination. The examination must have taken place within 18 months prior to May 15 of
the school year. A licensed dentist must complete the examination, sign and date this Proof of School Dental Examination Form. If you are unable
to get this required examination for your child, fill out a separate Dental Examination Waiver Form.
This important examination will let you know if there are any dental problems that need attention by a dentist. Children need good oral health to
speak with confidence, express themselves, be healthy and ready to learn. Poor oral health has been related to lower school performance, poor
social relationships, and less success later in life. For this reason, we thank you for making this contribution to the health and well-being of your
child.
To be completed by the parent or guardian (please print):
Student’s Name: Last First Middle
Birth Date:
(Month/Day/Year)
Address: Street City ZIP Code
Name of School:
ZIP Code
Grade Level: Gender:
FemaleMale
Parent or Guardian: Last Name First Name
Student’s Race/Ethnicity:
□ White □ Black/African American □ Hispanic/Latino □ Asian
□ Native American □ Native Hawaiian/Pacific Islander □ Multi-racial □ Unknown
□ Other_______________________________
To be completed by dentist:
Date of Most Recent Examination:
Sealant
Fluoride treatment
Restoration of teeth due to caries
Oral Health Status (check all that apply)
Yes No Dental Sealants Present on Permanent Molars
Yes No Caries Experience / Restoration History —
A filling (temporary/permanent) OR a tooth that is missing because it was
extracted as a result of caries OR missing permanent 1st molars.
Yes No Untreated Caries —
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
considered sound unless a cavitated lesion is also present.
Yes No Urgent Treatment — abscess, nerve exposure, advanced disease state, signs or symptoms that include pain, infection, or
swelling.
Treatment Needs (check all that apply). For Head Start Agencies, please also list appointment date or date of most recent treatment
completion date.
Restorative Care — amalgams, composites, crowns, etc. Appointment Date:
Preventive Care — sealants, fluoride treatment, prophylaxis Appointment Date:
Pediatric Dentist Referral Recommended Treatment Completion Date:
Additional comments:
Signature of Dentist License #: Date:
Illinois Department of Public Health, Division of Oral Health
217-785-4899 • TTY (hearing impaired use only) 800-547-0466 • www.dph.illinois.gov
IOCI 0600-10 Printed by Authority of the State of Illinois
(Check all services provided at this examination date)
Dental Cleaning
