Ohio Department of Health   • School and Adolescent  Health
Oral Assessment

Student’s name	Date of birth
/	/

The following services have been performed (please check all that apply)

a Examination	a Fluoride application	a Oral prophylaxis (cleaning)	a Prescription for fluoride supplement	
a Orthodontic  assessment	a Radiographs	a Dental sealant	a Treatment (restoration, pulp therapy)	
a Other 	

The following oral hygiene instruction was provided (please check all that apply)

a Toothbrushing 	a Flossing	a Dietary counseling	a Use of fluoride mouthrinse
a Other 	

The following statements are applicable (please check all that apply)

a All necessary preventive services have been performed. (Fluoride treatment, prophylaxis)
a No restorative services are required at this time.
a Further treatment is indicated.(See comments)
a Further appointments have been arranged. (Orthodontic,  restorative)
a Routine recall visits recommended.

Comments

Dentist’s signature	Print name	Phone
( 	)	
Address	Date
/	/	
City	State	ZIP	

HEA 4243  8/06