Preschool Oral Health Preliminary Exam Form And Prevention Services

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STATE OF WISCONSIN
DEPARTMENT OF HEALTH SERVICES
Division of Public Health
F-40335 (Rev. 07/08)
PRESCHOOL ORAL HEALTH PRELIMINARY EXAM AND PREVENTION SERVICES
Participation is voluntary, information collected on this form will be used for tracking treatment, and services provided to the patient and will be used only for this
purpose. See instructions below.
Date of Preliminary Examination
Site
Initials - Examiner
(mm/dd/yyyy)
PARTICIPATION INFORMATION
Identification Number
Birth Date (mm/dd/yyyy)
Age
Gender
Race and Ethnicity
1=Male
1=White
5= American Indian/Alaska Native
2= Female
2=African-American
6=Native Hawaiian/Pacific Islander
3=Hispanic
7=Multi-racial
4=Asian
9=Unknown
Untreated Caries
Caries Experience
0=No untreated cavities
0=No caries experience
1=Untreated cavities
1=Caries experience
Early Childhood Caries
Treatment Urgency
0=No ECC
0=No obvious problem
1=ECC present
1=Early dental care
2=Urgent care
Caries Risk Assessment-check all that -apply-one or more indicates risk
Clinical Conditions
Missing
Untreated or treated caries
F
E
Enamel demineralization (white spots)
G
D
H
C
Gingivitis or visible plaque
Decayed
B
I
Wearing dental or orthodontic appliances
Poorly formed enamel, deep pits
J
A
Filled
Radiographic enamel caries
3
14
Environmental Characteristics
Suboptimal systemic fluoride exposure
Right
Left
Suboptimal topical fluoride exposure
Comments:
Frequent consumption of cariogenic foods/ bev.
30
19
Irregular or no usual source of dental care
K
T
Low income
L
S
Special health care needs
M
R
Active caries present in the mother
N
Q
P
O
General Health Conditions
Special health care needs
Conditions impairing saliva composition/flow
Community Water Fluoridation Status
No obvious
Refer
COMMENTS
0=No
problem
‘R’
1=Yes
Head and Neck
Dietary Fluoride Supplementation Status
Lymph Nodes
0=No, community or well is not fluoridated, not aware of
Pharynx
fluoride level*
*Recommend water testing to determine fluoride level
Tonsils
1=Yes, currently uses dietary fluoride supplements
Soft Palate
2=NA, community water or well has optimal fluoride level
Hard Palate
Special Health Care Needs
Floor of Mouth
0=No
Lips
1=Yes
Skin
Fluoride Varnish Application Indicated
TMJ
0=No
Tongue
1=Yes
Vestibules
Documented caries risk
Buccal Mucosa
Has no contraindications to fluoride varnish (allergy, stomatitis)
Documented parental permission
Additional Comments:
Fluoride Varnish Application Schedule -.25ml (preschool)
1. Application Date ______Provider Initials_________
2. Application Date ______Provider Initials_________
3. Application Date ______Provider Initials_________
Referral services complete - Date_____Initials_______
SIGNATURE – Dental Professional
1

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