PROOF OF SCHOOL DENTAL EXAMINATION FORM
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
st
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 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 • www.idph.state.il.us
Printed by Authority of the State of Illinois
S
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):
(
Month/Day/Year)
IOCI 0600-10
