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The document collects identifying information for the child, including name, age, sex, grade, and classroom location, plus address fields. It includes a tooth chart for right and left upper and lower dentition, and records whether the child is under dental treatment, treatment completion status, and examination date with the signature of the dental examiner and examiner 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    \nNAME OF SCHOOL                                                            \n\n| NAME OF CHILD   | AGE   | SEX  \u003Cbr>F  \u003Cbr>M   | GRADE   | SECTION/ROOM   |\n| --- | --- | --- | --- | --- |\n| Middle  \u003Cbr>First  \u003Cbr>Last   |  |  |  |  |\n\nADDRESS  \n\n| No.and Street   | City or Post Office   | Borough/Township   | County   | State   | Zip   |\n| --- | --- | --- | --- | --- | --- |\n\n# REPORT OF EXAMINATION\n\n\n|  | TOOTH  \u003Cbr>RIGHT   |  |  |  |  |  |  |  |  CHART  \u003Cbr>LEFT   |  |  |  |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |\n| UPPER   | 1   | 2   | 3   | 4  \u003Cbr>A   | 5  \u003Cbr>B   | 6  \u003Cbr>C   | 7  \u003Cbr>D   | 8  \u003Cbr>E   | 9  \u003Cbr>F   | 10  \u003Cbr>G   | 11  \u003Cbr>H   | 12  \u003Cbr>I   | 13  \u003Cbr>J   | 14   | 15   | 16   | Upper   |\n| LOWER   | 32   | 31   | 30   | 29  \u003Cbr>T   | 28  \u003Cbr>S   | 27  \u003Cbr>R   | 26  \u003Cbr>Q   | 25  \u003Cbr>P   | 24  \u003Cbr>0   | 23  \u003Cbr>N   | 22  \u003Cbr>M   | 21  \u003Cbr>L   | 20  \u003Cbr>K   | 19   | 18   | 17   | Lower   |\n| UPPER   |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Upper   |\n| LOWER   |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Lower   |\n\nIs The Child Under Treatment?Yes □No □  \nNo □  \nYes □  \nTreatment Completed  \n\n| Date of Dental Examination   |\n| --- |\n| Signature of Dental Examiner   |\n| Address   |\n\n—          :","cbCaip24BTED2CE9","https://ap.wps.com/l/cbCaip24BTED2CE9","pdf",45250,"English","# Report of Examination\n## Child Information\n## Dental Chart\n## Treatment Status & Examiner Details","[{\"question\":\"What information about the child is collected in the report?\",\"answer\":\"The report records the child’s name, age, sex, grade, section/room, and address details.\"},{\"question\":\"What does the dental chart section include?\",\"answer\":\"It provides a tooth chart with right and left markings for upper and lower teeth to document findings.\"},{\"question\":\"How is dental treatment status recorded?\",\"answer\":\"The form asks whether the child is under treatment and whether treatment is completed, and it includes the date of the dental examination plus the examiner’s signature and address.\"}]","Private Dentist Report - Dental Exam Report | PDF",1790415739]