Get IL DPH IOCI 0600-10

State of Illinois Illinois Department of Public Health PROOF OF SCHOOL DENTAL EXAMINATION FORM To be completed by the parent please print Student s Name Address Last Street First Middle City Birth Date ZIP Code Name of School Grade Level Parent or Guardian Address of parent/guardian Month/Day/Year MM / DD / YYYY Telephone Gender Male Female Oral Health Status check all that apply Yes No Dental Sealants Present No Caries Experience / Restoration History A filling temporary/permanent OR a tooth that is missing because it was extracted as a result of caries OR missing permanent 1st molars. No Untreated Caries No Soft Tissue Pathology At least 1/2 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. No Malocclusion Treatment Needs check all that apply Urgent Treatment abscess nerve exposure advanced disease state signs or symptoms that include pain infection or swelling Restorative Care amalgams composites crowns etc* Preventive Care sealants fluoride treatment prophylaxis Other periodontal orthodontic Please note Signature of Dentist Date of Exam Address Telephone 217-785-4899 TTY hearing impaired use only 800-547-0466 www. No Untreated Caries No Soft Tissue Pathology At least 1/2 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. 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. 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. No Malocclusion Treatment Needs check all that apply Urgent Treatment abscess nerve exposure advanced disease state signs or symptoms that include pain infection or swelling Restorative Care amalgams composites crowns etc* Preventive Care sealants fluoride treatment prophylaxis Other periodontal orthodontic Please note Signature of Dentist Date of Exam Address Telephone 217-785-4899 TTY hearing impaired use only 800-547-0466 www. No Untreated Caries No Soft Tissue Pathology At least 1/2 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. .