0920-23FJ Attachment 2A_Data collection form A

ATTACHMENT: DATA COLLECTION FORM PART A

CLINICAL DENTAL SCREENING FORM

Examiner Initials:		Date (MM/DD/YYYY):
School Code:		Grade:
Student Pseudo ID:	Sex:   Female          Male		Age (Years):

Caries and Sealant Status of Permanent First and Second Molars

Tooth	Tooth Number	Sound	Sealed	Untreated cavitated decay	Restoration including crown	Missing	Unerupted or cannot be assessed
UR2M	2
UR1M	3
UL1M	14
UL2M	15
LL2M	18
LL1M	19
LR1M	30
LR2M	31

Fluorosis Status of Upper Anterior Teeth

Tooth	Tooth Number	Normal/Questionable	Very Mild	Mild	Moderate	Severe	Missing, unerupted, restoration/crown or other reason cannot be assessed
URC	6
URLI	7
URCI	8
ULCI	9
ULLI	10
ULC	11

Treatment Urgency:

Routine

Early

Urgent

Notes

UR2M: Upper right second permanent molar. UR1M: Upper right first permanent molar. UL1M: Upper left first permanent molar. UL2M: Upper left second permanent molar. LL2M: Lower left second permanent molar. LL1M: Lower left first permanent molar. LR1M: Lower right first permanent molar. LR2M: Lower right second permanent molar.

URC: Upper right cuspid. URLC: Upper right lateral incisor. URCI: Upper right central incisor. ULCI: Upper left central incisor. ULLI: Upper left lateral incisor. ULC: Upper left cuspid.