FREE 5+ Dental Examination Forms in PDF | MS Word

Maintaining good oral health is important for any individual at any age. This is because one’s oral health can affect his entire well-being which can cause severe heart diseases, diabetes, and even preterm labor. For this reason, an individual must visit the dentist occasionally to ensure that his oral health is not in jeopardy. During the visit to the dentist, a staff of the dentist’s office will provide the patient with a dental examination form which he must fill out.

Dental Examination Form Sample

What Are Dental Examination Forms?

Dental examination forms are documents which are prepared by dental health care service providers for their patients and clients. The form is often to be completed by both the patient and the dentist or the dental health professional who is administering the needs and treatments of the patient. In the form, the patient will have to disclose his information which will then be followed by the examinations and observations of the dentist regarding the patient’s oral health.

Dental Examination Record Form

Who Uses Dental Examination Forms?

Dental examinations forms are not only to be used and be kept by dentists or oral health care providers but also institutions such as schools and companies. The reason for this is to document and prove that an individual has undergone the required dental examination prior to his participation in the institution. Also, by having the dental examination form, the institution will be able to know and acknowledge what types of treatments will be needed by their member or their employee, and determine whether or not the treatment needs are included in the insurance coverage of the patient which was provided by the institution.

How to Create a Basic Dental Examination Form

There are dental and oral health care providers who are still new in the industry, and still in the process of navigating what they will be needing and what their patients will need. For these starters, a basic or a general type of dental examination form can be used. To begin creating this form, the enlisted steps below must be followed:

Step 1: Open a word-processing software application. Every electronic device will have different applications installed and specifically made which are compatible with its specs and features. This is why there are several types of word-processing software applications that one can use for creating documents and forms. However, the most common application is the Microsoft Word software application which results in having a document in a “.doc” or in “.docx” file extension.

Step 2: Set the measurements for the document sheet. Some word-processing software applications immediately create a new document upon opening the application, while there are others which gives options to the user of what type and what format will be used. Nonetheless, when preparing the sheet for the examination form, the measurements of the margin, the types of fonts to be used and its size, and even the indentations and styles should be specified before placing any content.

Step 3: Add a document header. Most dental health care centers have their own brand headers while there are others who do not. If there is a ready-made header, then it should be placed into the topmost portion of the document sheet. On the other hand, if the dentist does not have his own brand header, then a header should be made in the form. The header should contain the name of the dental health care center, its contact information, address, as well as its schedules. In addition, the title of the form should also be placed right below the header with emphasis on its style.

Step 4: Create a patient information section. This will be the first part of the form which should be filled out by the patient before he proceeds to meet the dentist. In the patient information section, the full name of the patient, the date of his appointment, the frequency of him performing his oral hygiene practices, his methods of his oral hygiene, as well as his self-assessment and his observations of his gums are some of the details to be disclosed. Aside from the patient’s information, a signature area can also be added in this section of the form which is for the signature of the patient’s caretaker or legal guardian if the patient is not capable of filling out the form or if the patient needed additional assistance due to his medical condition.

Step 5: Incorporate a dental notation chart illustration. A dental notation chart is an illustration of a set of teeth with numbers assigned to each tooth. The purpose of this notation is to allow the dentist in identifying and labeling which areas of the patient’s teeth and gums have issues to address to and whether the patient has a missing tooth or a grown tooth in a specific position which can cause a danger to the patient’s oral health.

Step 6: Allocate a section for the dentist’s observations. This section should be below the dental notation chart illustration since this is where the dentist will be able to disclose his dental assessments. Each assessment type or category should have separate areas and lines allocated for it in order for the dentist to specify and state details about his observations. Some of the assessments to include in this section are the patient’s denture conditions, gum ulceration, and abnormal teeth growth.

Step 7: Include an appointment information section. This is where the dentist can indicate the tests that he was able to administer to the patient as well as the recommendations and plans that he wants the patient to consider following for his oral health. Moreover, the date and time of the patient’s next appointment schedule should also be indicated in the appointment information section to allow the front desk or the staff of the dental health care center in recording the patient’s appointment on the stated day in the dentist’s calendar.

Step 8: Save and convert the form. The dental examination form must be saved in a format which can be used again or be edited and updated in the future. On the other hand, the form can also be converted into other formats for different purposes such as for online appointment scheduling wherein a dental examination form in “.pdf” format is preferable to be used.

Pre-Kindergarten Dental Examination Form

Examples of Dental Examination Forms

The varieties of dental examination forms differ on the range of data and information which are collected in each field of the form. Below are some examples of dental examination forms that dental health care centers and professionals can use:

Defense Officer Dental Examination Form – People who are employed in the field of security and defense services are also required to undergo dental examinations by their employers especially if the individual plans to be part of the State’s military where dental issues can be the cause of his disqualification. For this, a defense officer dental examination form must be used to obtain detailed information about the dental health of the patient or the military personnel. In the form, there is a section for enlisting the privacy act rules and regulations with regards to the confidential information stated in the form.

Defense Officer Dental Examination Form

The name of the military service personnel or the officer along with his social security number, branch of service, unit of assignment, and the address of his unit will be the types of personal data to be disclosed in the form. These pieces of information will then be followed by the examination results to be filled out by the physician or the dentist of the personnel. Lastly, the dentist’s name, contact information, address, license number, and his signature will be needed to complete the form as well as the date when the examination was administered.

Dental Examination Proof Form – This is the variety of dental examination form which is intended to be documented by an educational institution to prove that they have administered a test to their students and school faculty employees. The dental examination proof form will have three main sections to be completed by the involved parties. The first part of the form is the student information section which will be for gathering the name of the student taking the examination along with his date of birth, complete residential address, the name of the school that he is attending in, his current grade level, his gender, and the name and address of his parent or legal guardian.

Dental Examination Proof Form

The second and third part of the form is to be completed by the dentist. This is where the oral health status of the student will be identified of whether he has dental sealants present, or that he had undergone a restoration before, untreated caries, soft tissue pathology, and malocclusion. In addition, the dental treatments that the student needs ranging from restorative and preventive care should also be disclosed in this part of the form.

Dental Examination Waiver Form – There are some States and countries who require students and their citizens to take a dental and medical examination. However, the requirement waives specific individuals such as those who are scholars or grant members. In order to report to the State agency that a student is waived from the examination, a dental examination waiver form should be filled out by the student and his legal guardian.

Dental Examination Waiver Form

A dental examination waiver form will collect the basic information of the student along with the data of his guardian. In the second section of the form, a statement with a list of valid reasons why the student did not obtain the examination is incorporated. The student should mark the item on the list which indicates his reason such as his involvement in the reduced lunch program of the institution, and the unavailability of dental service providers who will cater the insurance that he is listed as a beneficiary.

Once a dental examination form is completed, the dentist must not only provide a summary of the observations and assessments that he made, rather he must give details and explain his assessments using basic terms or language to the patient. This ensures that the patient will be able to know and understand the condition of his oral health effectively, and if he ever has concerns, he can raise a question to the dentist without any delay.