Illinois Administrative Code
Title 77 - PUBLIC HEALTH
Part 665 - CHILD AND STUDENT HEALTH EXAMINATION AND IMMUNIZATION CODE
Subpart F - EYE EXAMINATION
Appendix D - Illinois Department of Public Health Dental Examination Form

Student's Name: LastFirstMiddle

Birth Date:

(Month/Day/Year)

/ /

Address: StreetCityZIP Code

Telephone:

Name of School:

Grade Level:

Gender:

MaleFemale

Parent or Guardian:

Address (of parent/guardian):

[] Yes[] No

Dental Sealants Present

[] Yes[] No

Caries Experience / Restoration History- A filling (temporary or permanent) OR a tooth that is missing because it was extracted as a result of caries OR missing permanent 1st molars. Include both treated and untreated decay.

[] Yes[] No

Untreated Caries - 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.

[] Yes[] No

Soft Tissue Pathology

[] Yes[] No

Malocclusion

[]

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

_____________________

Street

_______________________

City

______________

Zip Code

______________