Appendix A Pollard Dental Screening Exam Students Name: _____________________________________ DOB: ________________________ School: ______________________________ ___________________________ Patient’s Dentist: Date of Exam:_____________________________ Examiner: ________________________________ Oral Hygiene    Good Fair Poor Teeth Present: Treatment needed:______________________ _______________________________________ _______________________________________ ________________________________________ Sticker placed here with teeth Previously Treated Teeth:__________________ ________________________________________ ________________________________________ Needs to be seen  Before  For regular check-ups regular check-up As soon as possible Fluoride applied Fluoride Varnish Silver Diamine fluoride None Visit # 1 2 Parent Letter Dentist list sent Nurse notified
Appendix A Pollard Dental Screening Exam Students Name: _____________________________________ DOB: ________________________ School: ______________________________ Patient’s Dentist: ___________________________ Date of Exam:_____________________________ Examiner: ________________________________ Oral Hygiene  Good  Fair  Poor Teeth Present: Treatment needed:______________________ _______________________________________ _______________________________________ ________________________________________ Sticker placed here with teeth Previously Treated Teeth:__________________ ________________________________________ ________________________________________ Needs to be seen  For regular check-ups Before regular check-up  As soon as possible Fluoride applied Fluoride Varnish Silver Diamine fluoride None Visit # 1 2 Parent Letter Dentist list sent Nurse notified