Private Dentist Report Of Dental Examination Of A Pupil Of School Age
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1H514.027
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF HEALTH
PRIVATE DENTIST REPORT OF
DENTAL EXAMINATION OF A PUPIL OF
SCHOOL AGE
Holy Name of Jesus School, Harrisburg, PA
NAME OF SCHOOL ________
_________DATE_________________20_____
NAME OF CHILD
AGE
SEX
GRADE
SECTION/ROOM
M
F
LAST
FIRST
MIDDLE
ADDRESS
No. and Street
City or Post Office
Borough or Township
County
State
Zip
REPORT OF EXAMINATION
TOOTH CHART
RIGHT
LEFT
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
UPPER
Upper
A
B
C
D
E
F
G
H
I
J
32
31
30
29
28
27
26
25
24
23
21
20
19
18
17
LOWER
22M
Lower
T
S
R
Q
P
O
N
L
K
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
PrivDentRptExam/Rev1/20/2016
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