H514.027
COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF HEALTH

PRIVATE DENTIST REPORT
OF DENTAL EXAMINATION OF A PUPIL OF SCHOOL AGE

NAME OF SCHOOL________________________________________________DATE ____________________20 ___

NAME OF CHILD

_____________________________________________________________ Last	First	Middle
	AGE
	SEX

         M              F
	GRADE
	SECTION/ROOM

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

Treatment Completed

Yes 	No 

Yes 	No 

_________________________________________________ Date of Dental Examination

_________________________________________________ Signature of Dental Examiner

_________________________________________________ Print Name of Dental Examiner

_________________________________________________ Address