Section 665.APPENDIX D Illinois Department of Public Health Dental Examination Form

Illinois Department of Public Health

PROOF OF SCHOOL DENTAL EXAMINATION FORM

To be completed by the parent (please print):

Student's Name: Last First Middle		Birth Date: (Month/Day/Year) / /
Address: Street City ZIP Code		Telephone:
Name of School:	Grade Level:	Gender: Male Female
Parent or Guardian:	Address (of parent/guardian):

To be completed by dentist:

Oral Health Status (check all that apply)

q Yes q No	Dental Sealants Present
q Yes q No	Caries Experience / Restoration History − A filling (temporary or permanent) OR a tooth that is missing because it was extracted as a result of caries OR missing permanent 1^st molars. Include both treated and untreated decay.
q Yes q No	Untreated Caries − At least ½ 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.
q Yes q No	Soft Tissue Pathology
q Yes q No	Malocclusion

Treatment Needs (check all that apply)

q	Urgent Treatment − abscess, nerve exposure, advanced disease state, signs or symptoms that include pain, infection or swelling
q	Restorative Care − amalgams, composites, crowns, etc.
q	Preventive Care − sealants, fluoride treatment, prophylaxis
q	Other − periodontal, orthodontic
q	Please note

Signature of Dentist

Date of Exam

(Source: Added at 33 Ill. Reg. 8459, effective June 8, 2009)