Free Oral Health Preliminary Exam and Prevention Services - Wisconsin

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Date: March 16, 2009
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State: Wisconsin
Category: Health Care
Author: DHS
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Page Size: Letter (8 1/2" x 11")

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DEPARTMENT OF HEALTH SERVICES Division of Long Term Care F-00050 (03/2009)


Participation is voluntary, information collected on this form will be used for tracking treatment, and services provided to the patient and will be used only for this purpose. See instructions below.

Date of Preliminary Examination (mm/dd/yyyy) PARTICIPATION INFORMATION Identification Number


Initials - Examiner

Birth Date (mm/dd/yyyy)


Race and Ethnicity Gender 1=White 3=Hispanic 5=American Indian/Alaska Native 7=Multi-racial 1=Male 2=African-American 4=Asian 6=Native Hawaiian/Pacific Islander 9=Unknown 2=Female Untreated Caries Caries Experience 0=No untreated cavities 1=Untreated cavities 0=No caries experience 1=Caries experience Edentulous Treatment Urgency 0=No permanent teeth 1=At least one permanent tooth 0=No obvious problem 1=Early dental care 2=Urgent care Caries Risk Assessment: check all that apply, one or more indicates risk Missing Decayed Filled Clinical Conditions Untreated or treated caries Enamel demineralization (white spots) Gingivitis or visible plaque Comments: Wearing dental or orthodontic appliances Poorly formed enamel, deep pits Radiographic enamel caries Environmental Characteristics Suboptimal systemic fluoride exposure Suboptimal topical fluoride exposure Frequent consumption of cariogenic foods/bev. Irregular or no usual source of dental care Economic or geographic barriers to dental care Special Health Care Needs Special diets Behavioral problems Injuries related to seizure disorders or hyperactivity Inadequate oral hygiene due to mental capabilities, cognitive or motor delays Medications Neuromuscular (drooling, gag reflex, swallowing problems) Uncontrolled body movements Cardiac disorders Gastroesophageal reflux Visual impairment Latex allergies Community Water Fluoridation Status No obvious Refer COMMENTS problem `R' 0=No 1=Yes Head and Neck Prescription Fluoride (prevedent, omni-gel etc.) Lymph Nodes 0=No, 1=Yes, currently uses _____________________________ Pharynx Tonsils Special Health Care Needs Soft Palate 0=No 1=Yes Hard Palate Fluoride Varnish Application Indicated Floor of Mouth 0=No 1=Yes Documented caries risk Lips Has no contraindications to fluoride varnish (allergy, stomatitis) Skin Documented parental permission TMJ Tongue Vestibules Fluoride Varnish Application Schedule Dosage .25 or .40 Buccal Mucosa 1. Application Date ______Provider Initials_________ Periodontal Assessment (pain, swelling, bleeding etc.) 2. Application Date ______Provider Initials_________ 3. Application Date ______Provider Initials_________ Referral services complete Date _____ Initials _______ SIGNATURE Dental Professional


F-00050 (03/2009)


1. 2. 3. 4. 5.

The Site is the name of the agency. The Identification Number i.e., patient record number For screening information refer to Basic Screening Surveys: An Approach to Monitoring Community Oral health, 1999, ASTDD, for completing the PARTICIPANT INFORMATION section of the form. For caries risk assessment refer to Integrating Preventive Oral Health Measures into Healthcare Practice, Wisconsin Department of Health Services Address any questions to: DEPARTMENT OF HEALTH SERVICES DLTC/BLTS/Community Integration Public Health Educator 1 West Wilson Street, Room B138 Madison WI 53702