To be completed by the parent (please print):
State of Illinois
Illinois Department of Public Health
To be completed by dentist:
Oral Health Status (check all that apply)
Yes No Dental Sealants Present
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 1
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 consid-
ered sound unless a cavitated lesion is also present.
Yes No Soft Tissue Pathology
Yes No Malocclusion
Treatment Needs (check all that apply)
Urgent Treatment abscess, nerve exposure, advanced disease state, signs or symptoms that include pain, infection, or swelling
Restorative Care amalgams, composites, crowns, etc.
Preventive Care sealants, fluoride treatment, prophylaxis
Other periodontal, orthodontic
Please note____________________________________________________________________________________
Signature of Dentist _________________________________________ Date of Exam ____________________
Address ___________________________________________________ Telephone _______________________
Street City ZIP Code
Illinois Department of Public Health, Division of Oral Health
217-785-4899 TTY (hearing impaired use only) 800-547-0466
Printed by Authority of the State of Illinois
tudent’s Name: Last First Middle Birth Date:
Address: Street City ZIP Code Telephone:
Name of School: Grade Level: Gender:
Male Female
Parent or Guardian: Address (of parent/guardian):
IOCI 0600-10