Kentucky Dental Screening/examination Form For School Entry - Kentucky
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1OAS/DSS
Kentucky Dental Screening/Examination Form for School Entry
KDESHS005
Kentucky law, KRS 156.160(i), requires proof of a dental screening or examination by a dentist, dental hygienist, physician, registered nurse, advanced
registered nurse practitioner, or physician assistant. This evidence shall be presented to the school no later than January 1 of the first year that a five (5)
or six (6) year old is enrolled in public school.
Test Type (check one)
Student Name:
___________________________________________________
Last
First
Middle
□
□
□
Screening
Birth date:
_/______/
Gender:
0 Male
1 Female
□
Exam
Parent or Guardian:___________________________________________________
Screener's Name:
________________________________
Name
Relationship
Screener's Address: ___________________________________
Address:__________________________
City: ___________________________
____________________________________________________
Phone Number:____________________ Screening Date:____________
Phone Number:_____________________
School:_________________________
Screener's Signature:_________________________________________
Date of Exam/Screening _____/______/______
Professional affiliation: (Please check one)
□
□
Dentist
Dental Hygienist
Untreated Decay:
Treated Decay:
(Check one)
(Check one)
□
□
□
□
Physician Assistant
Registered
0 No untreated cavities
0 No treated cavities
Nurse
with
training
□
□
□
□
1 Untreated cavities
APRN
Physician
1 Treated cavities
Pattern of Early Childhood
Treatment Urgency
Comments:
:
(Check one)
Cavities:
(Check one)
□
□
0 No Early Childhood Cavities
0 No obvious problem
□
1 Early dental care
□
needed
1 Early Childhood Cavities
□
Present
2 Referral for Urgent Care
NOTE: Comment required
if marked.
OH-12
3/16/2015
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