Illinois requires a dental examination for children in kindergarten and the second, sixth and ninth grades of public, private and parochial schools under the Child Health Examination Code (77 Ill. Adm. Code 665). A licensed dentist records the services provided, oral health status and treatment needs on this one-page IDPH form and signs it. The parent then turns it in to the school as proof of the exam.
The parent or guardian prints the student's name, birth date, address, school, grade level, gender and race/ethnicity at the top. A licensed dentist completes everything under 'To be completed by the dentist' and signs with a license number and date.
The parent prints the student's last, first and middle name, birth date (month/day/year), street address, city and ZIP code, school name and ZIP code, grade level and gender, then the parent or guardian's name. A row of checkboxes records the student's race/ethnicity, from White through Middle Eastern or North African, Two or More Races, Unknown and Other. This is the only part the parent completes; everything below 'To be completed by the dentist' belongs to the dental office.
Enter the date of the most recent examination and check every service provided on that date: dental cleaning, sealant, fluoride treatment, silver diamine fluoride, and restoration of teeth due to caries. The date matters because the form states the exam must have taken place within 18 months before May 15 of the school year, so the school can confirm the exam falls inside that window.
Answer Yes or No on four lines. Dental sealants present on permanent molars. Caries experience or restoration history, meaning a temporary or permanent filling, a tooth extracted because of caries, or missing permanent first molars. Untreated caries, defined as at least 1/2 mm of enamel loss with brown to dark-brown walls, counting a retained root as a destroyed tooth. Urgent treatment, meaning abscess, nerve exposure, advanced disease, or pain, infection or swelling.
Check restorative care (amalgams, composites, crowns), preventive care (sealants, fluoride treatment, prophylaxis) or pediatric dentist referral as needed. Each line has a space for an appointment date or recommended treatment completion date. The form asks dentists seeing children from Head Start agencies to list the appointment date or the date of the most recent treatment, so complete those dates whenever the child attends Head Start.
Enter the office address and phone, then sign, add your Illinois dental license number and date the form. The introduction states that a licensed dentist must complete the examination and sign and date the form, so a missing signature, license number or date leaves the proof incomplete. Hand the finished form to the parent or guardian, who turns it in to the school.
Download the current version from the source each time; forms change without notice.
Proof of School Dental Examination Form
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Sources for this guide
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Children in kindergarten and the second, sixth and ninth grades of any public, private or parochial school in Illinois need a dental examination under 77 Ill. Adm. Code 665. The exam must take place within 18 months before May 15 of the school year, and a licensed dentist must complete it and sign and date the Proof of School Dental Examination Form.
The form defines untreated caries as at least 1/2 mm of tooth structure loss at the enamel surface, with brown to dark-brown walls, on pits and fissures or smooth surfaces. A retained root counts as a tooth destroyed by caries. Broken or chipped teeth and teeth with temporary fillings are recorded as sound unless a cavitated lesion is also present.
Yes. IDPH posts a Spanish version, Formulario de prueba del examen dental escolar, with the same 4/26 printing as the English form, and a French version as well. The Dental Examination Waiver Form is also available in Spanish and French on the IDPH oral health page.
The parent completes the separate Dental Examination Waiver Form and checks the reason, such as the child being in the free and reduced lunch program without dental coverage, having Medicaid/All Kids with no dentist nearby who accepts it, or having no dental insurance and no low-cost clinic in the community.