Head Start Oral Health Form—Children Patient Information Child’s name n n Date of birth n n Parent’s/guardian’s name n n Phone number n n City Address This practice is the child’s dental home: Yes n n n State n Zip code No Current Oral Health Status Yes (decay) No (decay free) Does the child have any teeth with untreated decay? Does the child have any teeth that have previously been treated for decay, including fillings, crowns, or extractions? Yes No Yes, urgent Yes, not urgent No treatment needs Are there treatment needs? Oral Health Care Services Delivered During Visit Diagnostic/Preventive Services Examination: Yes No X-rays: Yes No Risk assessment: Yes No Cleaning: Yes No Fluoride varnish: Yes No Dental sealants: Yes No Counseling/Anticipatory Guidance Yes No Referral to Specialty Care Yes No Restorative/Emergency Care Fillings: Yes No Crowns: Yes No Extractions: Yes No Emergency care: Yes No Other: (Please specify specialist) (Please specify) Future Oral Health Care Services All treatment completed: Yes No No More appointments needed for treatment? Yes If yes: Approximate number of appointments needed: Next recall date: / Next appointment: Date: (month/year) Time: Additional Information for Parents, Head Start Staff, and Medical Providers Oral Health Provider’s Contact Information and Signature Provider name (please print) n n Phone number Practice name n n Address Provider signature n n Date of service n n Fax number This document was prepared under grant #9OHC0005 for the U.S. Department of Health and Human Services, Administration for Children and Families, Office of Head Start, by the National Center on Early Childhood Health and Wellness. This publication is in the public domain, and no copyright can be claimed by persons or organizations.