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.