H514.027                                             COMMONWEALTH OF PENNSYLVANIA  -   DEPARTMENT OF HEALTH
PRIVATE DENTIST REPORT OF DENTAL EXAMINATION OF A PUPIL OF SCHOOL AGE

NAME OF SCHOOL: Pope John Paul II Regional Catholic Elem. School             DATE: __________

NAME OF CHILD
_________________________________________
Last First Middle

AGE

SEX
M   F

GRADE

 SECTION/RM
ADDRESS
________________________________________________________________________________
No. and Street City or Post Office Borough or Township County State Zip

REPORT OF EXAMINATION

 

Tooth Chart
Right Left

  
Upper

1

2

3

4

A

5

B

6

C

7

D

8

E

9

F

10

G

11

H

12

I

13

J

14

15

16

Upper
Lower

32

31

30

29

T

28

S

27

R

26

Q

25

P

24

O

23

N

22

M

21

L

20

K

19

18

17

Lower
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