Form 1 Initial Dental Exam Form

OMB Control No: 0970-XXXX

Expiration date: XX/XX/XXXX

Initial Dental Exam
General Information (to be completed by shelter staff)
Child	Last name:			First name:
	DOB: ____/____/______	A#:				Gender:
Healthcare Provider	Name:		Phone number:		Clinic or Practice:
	Street address:		City or Town:		State:		Date of visit: ____/____/______
Program	Name of program staff with child:			Program name:
Assessment and Plan (To be completed by clinician)
Assessment: Check all that apply and describe where applicable.
Well-child/No obvious problem
Broken tooth or teeth:
Gingivitis/gum disease:
Impacted tooth or teeth:
Infection or abscess:
Tooth decay/caries: If yes, how many?
Tooth sensitivity:
Other, specify:
Plan: Check all that apply and specify in the space provided.
Return to clinic: PRN/As needed Follow-up (specify condition, timing): ______________________________________________________________________________________ ______________________________________________________________________________________
Referred to specialist; specify:
Other, specify:
Additional Information:

THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) Public reporting burden for this collection of information is estimated to average 5 minutes per response, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.