Kentucky Dental Screening/Examination Form for School Entry August 2010 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



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Kentucky Dental Screening/Examination Form for School Entry August 2010
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.



Student Name: ___________________________________________________

Last First Middle


Birth date: _/______/ Gender: □ 0 Male □ 1 Female

Parent or Guardian:___________________________________________________

Name Relationship

Address:__________________________ City: ___________________________

Phone Number:_____________________ School:_________________________
Date of Enrollment _____/______/______

This space intentionally left blank




Screener's Name: ________________________________
Screener's Address: ___________________________________
____________________________________________________
Phone Number:____________________ Screening Date:____________
Screener's Signature:_________________________________________

Professional affiliation: (Please check one)
□ Dentist □ Dental Hygienist

□ Physician Assistant □ LHD Registered

Nurse with

KIDS Smiles training

□ ARNP □ Physician




Untreated Decay: (Check one)
□ 0 No untreated cavities

□ 1 Untreated cavities




Treated Decay: (Check one)

□ 0 No treated cavities

□ 1 Treated cavities



Pattern of Early Childhood Cavities: (Check one)

□ 0 No Early Childhood Cavities


□ 1 Early Childhood Cavities

Present



Treatment Urgency: (Check one)

□ 0 No obvious problem

□ 1 Early dental care

needed


□ 2 Referral for Urgent Care

NOTE: Comment required



if marked.


Comments:


OH-12 (rev, 4/2010)


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