Comments: Data for SEALS Number of 1st molars Number of 2nd molars Number of permanent sealed: sealed: teeth sealed: (0 - 4) =_________________ (0 - 4) =_________________ (0 - 8) =_________________ Number of primary teeth Fluoride varnish provided: Prophylaxes provided: sealed: No/Yes No/Yes (0 - 8) =_________________ Follow-Up Chart for program use (Mark with an teeth where sealants were retained) “R” 1 2 3 4 5 12 13 14 15 16 Evaluator’s Signature _________________________ Date 32 31 30 29 28 21 20 19 18 17 _________________________ Comments: Data for Number of teeth with a retained sealant (0 8) –
Comments: Number of 1st molars sealed: (0 - 4) =_________________ Number of 2nd molars sealed: (0 - 4) =_________________ Number of permanent teeth sealed: (0 - 8) =_________________ Number of primary teeth sealed: (0 - 8) =_________________ Fluoride varnish provided: No/Yes Prophylaxes provided: No/Yes Data for SEALS Follow-Up Chart for program use (Mark with an “R” teeth where sealants were retained) 1 2 3 4 5 12 13 14 15 16 Evaluator’s Signature _________________________ Date _________________________ 32 31 30 29 28 21 20 19 18 17 Comments: Data for Number of teeth with a retained sealant (0 – 8)