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Record on Dental Chart: Deciduous teeth - d (Decayed), e (indicated for extraction), and f (filled) Permanent teeth - D (Decayed), M (Missing), and F (Filled) TOOTH CHARTRIGHTLEFT UPPER1234 A5 B6 C7 D8 E9 F10 G11 H12 I13 J141516 UPPER LOWER32313029 T28 S27 R26 Q25 P24 O23 N22 M21 L20 K191817 LOWER First Exam Upper UPPER Lower LOWER Second Exam Upper UPPER Lower LOWER Third Exam Upper UPPER Lower LOWER Fourth Exam Upper UPPER Lower LOWER Fifth Exam Upper UPPER Lower LOWERSTUDENT REFERRAL DATEEXAMINED OR EVALUATED BYREFERRED TOREMARKS (if yes, next page)1ST EXAMYes  FORMCHECKBOX  No  FORMCHECKBOX 2ND EXAMYes  FORMCHECKBOX  No  FORMCHECKBOX 3RD EXAMYes  FORMCHECKBOX  No  FORMCHECKBOX 4TH EXAMYes  FORMCHECKBOX  No  FORMCHECKBOX 5TH EXAM Yes  FORMCHECKBOX  No  FORMCHECKBOX OTHER Yes  FORMCHECKBOX  No  FORMCHECKBOX  NAME OF STUDENT ______________________________________________ DENTAL FINDINGS Check Applicable Items Grade DateEXAMINED OR EVALUATED BY Prophylaxis SPECIAL PROJECTS (Specify)FLUORIDEOral Evaluation Passed/ ReferredTOTALS Tooth Brush Instructions Nutrition CounselingTabletMouth RinseDef DMFOHI IndexK123456789101112Other REMARKS: DATE DATE  DATE DATE DATE DATE DATE      H514.027 (02/2013) 3NOPQ  ) ŵtcRAR0 hVh*CJOJQJ^JaJ hVhuCJOJQJ^JaJ hVh6RCJOJQJ^JaJ hR{chCJOJQJ^JaJ hVh6RCJOJQJ^JaJh=-L5CJOJQJ^JaJh*Y5CJOJQJ^JaJ#h*Yh*Y5CJOJQJ^JaJh*Yh*Y5CJOJQJ^Jh75OJQJ^JhkDXh6R5OJQJ^J hkDXh/CJOJQJ^JaJ hkDXhCJOJQJ^JaJ23OPS _kd$$Ifl0+'f " t0644 layt=-L $Ifgd6RPgd*Y$a$gd6R$a$gd ) E L ] ^ _ ` n o p w x y    ͼ͏ͼwfUGhVCJOJQJ^JaJ hVhuCJOJQJ^JaJ hR{chCJOJQJ^JaJ/jhR{ch>CJOJQJU^JaJ/jhR{ch>CJOJQJU^JaJ)jhR{ch6RCJOJQJU^JaJ h9h9CJOJQJ^JaJ hR{ch6RCJOJQJ^JaJ hVh*CJOJQJ^JaJ hVh6RCJOJQJ^JaJS Y ]    Xkd$$IfluF+"'f ` t06    44 layt=-L ($IfgdV $Ifgd6R     1 3 4 D E G H J U V w x ޻yhyhyhyhyhyhW hR{ch{CJOJQJ^JaJ h*Yh{CJOJQJ^JaJ#h*Yh{5CJOJQJ^JaJ h*Yh*YCJOJQJ^JaJ h*Yh*CJOJQJ^JaJh*CJOJQJ^JaJ hR{ch{CJOJQJ^JaJ#h*YhkDX5CJOJQJ^JaJ hR{ch6RCJOJQJ^JaJ h*Yh6RCJOJQJ^JaJ   $$Ifa$gd*jkdT$$Ifl' t0644 layt*Y  $$Ifa$gd*Ylkd$$Ifl' t0644 layt8u  $$Ifa$gdR{c $Ifgd6Rjkd$$Ifl' t0644 layt*Y           ! 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