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