Private Dental Form

H514.027 (08/2011-under review)

COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF 
HEALTH

 

PRIVATE  DENTIST  REPORT 
OF DENTAL EXAMINATION OF A PUPIL OF SCHOOL AGE

NAME OF SCHOOL                                                                         DATE___________________20 

NAME OF CHILD

 

  AGE

 

SEX

MF

 

   GRADE

 

  SECTION/ROOM

Last.                          First.                              Middle

ADDRESS

 

 

No. and  Street       City or.Post Office            Borough/Township              County               State           Zip

 

 

REPORT OF EXAMINATION

 

TOOTHCHART

 

 

RIGHT

 

LEFT

 

UPPER

I

2

3

4

A

5

B

6

C

7

D

8

E

9

F

10

G

11

H

12

I

13

J

14

15

16

 

Upper

 

LOWER

32

31

30

29

T

28

s

27

R

26

Q

25

p

24

0

23

N

22

M

21

L

20

K

19

18

17

 

Lower

 

UPPER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Uooer

 

LOWER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Lower

ls The  Child Under Treatment?                                                                  Yes 0           No   0

 

Treatment Completed                                                                                Yes  0           No.   0

 

_____________________
Date of Dental Examination

 

___________________________ ______________________________
Signature of Dental  Examiner                                               Print Name of Dental Examiner

____________________________________
Address