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

_________________________________________________ Last	First	Middle
	
AGE
	
SEX

M	F
	
GRADE
	
SECTION/ROOM

ADDRESS

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

REPORT OF EXAMINATION
	TOOTH CHART

RIGHT
	
LEFT

UPPER
	1
	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 O
	23 N
	22 M
	21 L
	20 K
	19
	18
	17
	
Lower

UPPER
																	
Upper

LOWER
																	
Lower

Is The Child Under Treatment?	Yes	No

Treatment Completed	Yes	No

__________________________________________ Date of Dental Examination

__________________________________________ Signature of Dental Examiner

__________________________________________ Print Name of Dental Examiner

__________________________________________ Address