Title: Proof of School Dental Examination Form
Author: LBILBREY

State of Illinois
Illinois Department of Public Health

PROOF OF SCHOOL DENTAL EXAMINATION FORM
Illinois law (Child Health Examination Code, 77 Ill. Adm. Code 665) states all children in kindergarten, second, sixth, and ninth grades of any public, private, or parochial school shall have a dental examination. The examination must have taken place within 18 months prior to May 15 of the school year. A licensed dentist must complete the examination, sign, and date this Proof of School Dental Examination Form. If you are unable to get this required examination for your child, fill out a separate Dental Examination Waiver Form.
This important examination will let you know if there are any dental problems that require attention by a dentist. Children need good oral health to speak with confidence, express themselves, be healthy, and ready to learn. Poor oral health has been related to lower school performance, poor social relationships, and less success later in life. For this reason, we thank you for making this contribution to the health and well-being of your child.

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To be completed by the parent or guardian (please print)
^Student's ^Name:	^Last	^First	^Middle	^Birth Date: ^(Month/Day/Year)

Address:	^Street		City		ZIP Code ^Name ^of ^School:		ZIP Code	Grade Level:
Parent or Guardian:	Last Name	First Name

□	□	□	□

Select from the below general racial category which most clearly reflects the student's recognition of his or her community or with which the student most identifies.
White	Black or African American	Hispanic or Latino	Asian ^D American Indian or Alaska Native	^D Native Hawaiian or Pacific Islander	^D Two or More Races

To be completed by dentist

Dental Cleaning	D Sealant	D Fluoride treatment	D Restoration of teeth due to caries

Date of Mo_Dst Recent Examination: 	__ ^(Check all services provided at this examination date^)
Oral Health Status
D Yes D No	Dental Sealants Present on Permanent Molars

□Yes □ No
□Yes □ No
□Yes □ 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.

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.

Urgent Treatment - abscess, nerve exposure, advanced disease state, signs or symptoms that include pain, infection, or swelling.

Treatment Needs (check all that apply). Please list appointment date or date of most recent treatment completion date.

D Restorative Care - amalgams, composites, crowns, etc. D Preventive Care - sealants, fluoride treatment, prophylaxis D Pediatric Dentist Referral Recommended

Appointment Date:	 Appointment Date:	 Treatment Completion Date:	

^Dental Off^ic^e ^Address:

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Signature of Dentist	Date
^Illinois ^Departm ^ent ^of ^Pub^lic ^Health, ^Division ^of ^Oral ^Health
217-785-4899 • TTY (hearing im paired use only) 800-547-0466 • www.dph.illinois.gov IocI0600-10
^Printed ^by ^Authority ^of ^the ^State ^of ^Illinois	Revised 06/2022	_�