Forms Used in The Program - smile-mohkw.com · Forms used in The Program 151 Operational Guide for...
11
Forms used in The Program 151 Operational Guide for School Oral Health Program Forms Used in The Program
Transcript of Forms Used in The Program - smile-mohkw.com · Forms used in The Program 151 Operational Guide for...
Forms usedin The Program
151151
Operational Guide for SchoolOral Health Program
Forms Used in The Program
Forms usedin The Program
Den
tist
:---
----
----
----
----
----
----
----
----
Mon
th:--------------------------
Cli
nic
:-------------
NO
Pro
ced
ure
12
34
56
78
910
1112
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Tota
l
1C
hart
ing &
Ora
l E
xam
inati
on
2O
ral
Pro
ph
yla
xis
3F
luori
de
Ap
pli
cati
on
4S
cali
ng
5F
issu
re S
eala
nt
6P
.R.R
7L
iner
8C
om
posi
te/G
lass
Ion
om
er F
illi
ng
9P
ulp
oto
my P
erm
an
ent
10
Pu
lpec
tom
y P
erm
an
ent
11A
pex
ogen
isis
12
Pu
lpoto
my /
Pu
lpec
tom
y P
rim
ary
13
Dir
ect
Pu
lp C
ap
pin
g
14
Ind
irec
t P
ulp
Cap
pin
g
15
Sta
inle
ss S
teel
Cro
wn
Pim
ary
16
Sta
inle
ss S
teel
Cro
wn
Per
man
ent
17
Tem
pora
ry F
illi
ng
18
Extr
act
ion
Per
man
ent
19
Extr
act
ion
Pri
mary
20
Tre
atm
ent
Com
ple
ted
(T
C)
21
Pre
ven
tion
Com
ple
ted
(P
C)
22
Em
ergen
cy T
reatm
ent
23
Med
icati
on
24
Res
eal
25
Ref
ill
26
Rec
all
Exam
inati
on
27
Per
man
ent
(TC
)
28
No T
reatm
ent
Req
uir
ed
29
Pati
ent
Vis
it (
KW
)
30
Pati
ent
Vis
it (
NK
)
31
Pati
ent
Vis
it (
Tota
l)
Den
tist
s M
on
thly
Pro
du
ctiv
ity
Na
tio
na
l O
ral
Hea
lth
Pro
gra
m
152152
Forms usedin The Program
Den
tist
:---
----
----
----
----
----
----
----
----
Mo
nth
:--------------------------
Cli
nic
:-------------
NO
Pro
ced
ure
12
34
56
78
910
1112
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Tota
l
1E
xam
inati
on
2E
mer
gen
cy T
reatm
ent
3P
eria
pic
al
X-R
ay N
o (
2)
4M
edic
ati
on
5P
ulp
oto
my /
Per
man
ent
6P
ulp
ecto
my/
Per
man
ent
7Ir
rigati
on
8C
lean
ing &
Sh
ap
ing
9A
pex
ogen
isis
10
Ap
exif
icati
on
11R
oot
Can
al
Fil
lin
g
12
Case
Com
ple
ted
13
Ret
reatm
ent
Fil
lin
g
14
Tem
pora
ry F
illi
ng
15
MT
A
16
Bro
ken
Ap
poin
tmen
t
17
Foll
ow
up
Vis
it
18
Pati
ent
Vis
it (
KW
)
19
Pati
ent
Vis
it (
NK
)
20
Pati
ent
Vis
it (
Tota
l)
Den
tist
s M
on
thly
Pro
du
ctiv
ity
fo
r R
oo
t C
an
al
Cli
nic
Na
tio
na
l O
ral
Hea
lth
Pro
gra
m
153153
Forms usedin The Program
Nat
iona
l Ora
l Hea
lth P
rogr
am
Den
tist
:---
----
----
----
----
----
----
----
Mo
nth
:--------------------------
Cli
nic
:--------------------------
NO
Pro
ced
ure
12
34
56
78
91
011
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
To
tal
1E
xa
min
ati
on
2Im
pre
ssio
n
3O
rth
o B
an
d A
pp
lica
tio
n
4B
itep
late
or
Bit
epla
ne
5E
last
ic S
epa
rato
r
6A
pp
lia
nce
Act
iva
tio
n
7S
p.
M.
Ba
nd
&L
oo
p
8S
p.
M.
Cro
wn
&L
oo
p
9S
p.M
. L
ing
ua
l A
rch
10
Sp
.M.
Pa
rtia
l D
entu
re
11N
an
ce A
pp
lia
nce
12
Sp
ace
Reg
ain
er
13
Tra
iner
14
Up
per
Ex
pa
nd
er
15
Up
per
Ex
pa
nd
er 3
D
16
Sa
git
tal A
pp
lia
nce
17
Ret
ain
er
18
Nig
ht
or
Mo
uth
Gu
ard
19
Lo
wer
Ex
pa
nd
er
20
Hea
dg
ear
21
Ha
bit
Bre
ak
er
22
Cro
ss B
ite
Ap
pli
an
ce
23
Em
erg
ency
Tre
atm
ent
24
Med
ica
tio
n
25
Ref
erra
l
26
Rem
ov
al
of
Sp
.M.
27
Re-
Cem
enta
tio
n o
f S
p.M
.
28
X-R
ay
29
Pa
tien
t V
isit
(K
W)
30
Pa
tien
t V
isit
(N
K)
31
Pa
tien
t V
isit
(T
ota
l)
Den
tist
s M
on
thly
Pro
du
ctiv
ity
fo
r S
pa
ce M
ain
tain
er C
lin
ic
Na
tio
na
l O
ral
Hea
lth
Pro
gra
m
154154
Forms usedin The Program
Hygie
nis
t:…
……
……
…M
on
th:--------------------------
Cli
nic
:-------------
NO
Pro
ced
ure
12
34
56
78
910
1112
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Tota
l
1G
rou
p B
rus
hin
g
2In
div
idu
al
Bru
sh
ing
3S
ca
lin
g
4O
ral
Pro
ph
yla
xis
5F
lou
rid
e A
pp
lic
ati
on
6F
iss
ure
Se
ala
nt
7R
es
ea
l
8P
rev
en
tio
n C
om
ple
ted
( P
C )
9B
rok
en
Ap
po
intm
en
t
10
OH
I &
To
oth
Bru
sh
ing
11
No
. o
f L
ec
ture
s
12
No
. o
f S
tud
en
ts
13
Pa
tie
nt
Vis
it (
KW
)
14
Pa
tie
nt
Vis
it (
NK
)
15
Pa
tie
nt
Vis
it (
To
tal
)
Nati
on
al
Ora
l H
ealt
h P
rogra
m
Hy
gie
nis
ts's
Mo
nth
ly P
rod
uct
ivit
y
155155
Forms usedin The Program
156156
Forms usedin The Program
157157
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MINISTRY OF HEALTH - DENTAL ADMINISTRATION - SCHOOL ORAL HEALTH PROGRAM
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Preventive Consent Form
Forms usedin The Program
Treatment Consent Form/School
158158
Forms usedin The Program
Treatment Consent Form/Centre
159159
Forms usedin The Program
Sch
oo
l O
ra
l H
ea
lth
Pro
gra
m,
Ku
wa
it-F
orsy
th (
Pri
ma
ry S
cho
ols
)
Pre
ven
tio
n C
ha
rt f
or
Mo
bil
e T
eam
s
Sch
ool
Nam
e a
nd
Co
de:
S
tud
ent
Na
me:
C
ivil
ID
:
P
rog
ram
:
1
st G
rad
e
2
nd G
rad
e
3rd G
rad
e
4
th G
rad
e
5
th G
rad
e F
luo
rid
e 1
stA
pp
lica
tio
n(D
ate)
:
Flu
ori
de
2n
dA
pp
lica
tio
n(D
ate)
:
(Giv
e re
aso
n i
f n
ot
app
lied
)
Pit
an
d F
issu
re S
ea
lan
ts (
Ro
un
d o
ff
Ap
pro
pri
ate
cod
es)
Co
des
an
d s
tats
:
X-U
n-e
rup
ted
:
1-P
arti
ally
eru
pte
d:
2-S
eale
d B
efo
re a
nd
So
un
d:
3-S
ou
nd
an
d s
eale
d n
ow
:
4-E
arly
les
ion
an
d s
eale
d n
ow
:
5-R
esea
led
no
w:
6-S
ou
nd
bu
t n
ot
seal
ed(R
easo
n):
7-
Dec
ayed
an
d r
efer
red
:
8-
Oth
ers:
Op
era
tor:
Da
te:
Co
mm
ents
:……
……
……
……
……
……
To
oth
#
C
od
es
17
X
1
2
3
4
5
6
7
8
16
X
1
2
3
4
5
6
7
8
15
X
1
2
3
4
5
6
7
8
14
X
1
2
3
4
5
6
7
8
24
X
1
2
3
4
5
6
7
8
25
X
1
2
3
4
5
6
7
8
26
X
1
2
3
4
5
6
7
8
27
X
1
2
3
4
5
6
7
8
37
X
1
2
3
4
5
6
7
8
36
X
1
2
3
4
5
6
7
8
35
X
1
2
3
4
5
6
7
8
34
X
1
2
3
4
5
6
7
8
44
X
1
2
3
4
5
6
7
8
45
X
1
2
3
4
5
6
7
8
46
X
1
2
3
4
5
6
7
8
47
X
1
2
3
4
5
6
7
8
Flu
ori
de
1stA
pp
lica
tio
n(D
ate)
:
Flu
ori
de
2n
dA
pp
lica
tio
n(D
ate:
(Giv
e re
aso
n i
f n
ot
app
lied
)
Pit
an
d F
issu
re S
ea
lan
ts (
Ro
un
d o
ff
Ap
pro
pri
ate
cod
es)
Co
des
an
d s
tats
:
X-U
n-e
rup
ted
:
1-P
arti
ally
eru
pte
d:
2-S
eale
d B
efo
re a
nd
So
un
d:
3-S
ou
nd
an
d s
eale
d n
ow
:
4-E
arly
les
ion
an
d s
eale
d n
ow
:
5-R
esea
led
no
w:
6-S
ou
nd
bu
t n
ot
seal
ed(R
easo
n):
7-
Dec
ayed
an
d r
efer
red
:
8-
Oth
ers:
Op
era
tor:
Da
te:
Co
mm
ents
:……
……
……
……
……
……
To
oth
#
C
od
es
17
X
1
2
3
4
5
6
7
8
16
X
1
2
3
4
5
6
7
8
15
X
1
2
3
4
5
6
7
8
14
X
1
2
3
4
5
6
7
8
24
X
1
2
3
4
5
6
7
8
25
X
1
2
3
4
5
6
7
8
26
X
1
2
3
4
5
6
7
8
27
X
1
2
3
4
5
6
7
8
37
X
1
2
3
4
5
6
7
8
36
X
1
2
3
4
5
6
7
8
35
X
1
2
3
4
5
6
7
8
34
X
1
2
3
4
5
6
7
8
44
X
1
2
3
4
5
6
7
8
45
X
1
2
3
4
5
6
7
8
46
X
1
2
3
4
5
6
7
8
47
X
1
2
3
4
5
6
7
8
Flu
ori
de
1stA
pp
lica
tio
n(D
ate)
:
Flu
ori
de
2n
dA
pp
lica
tio
n(D
ate)
:
(Giv
e re
aso
n i
f n
ot
app
lied
)
Pit
an
d F
issu
re S
ea
lan
ts (
Ro
un
d o
ff
Ap
pro
pri
ate
cod
es)
Co
des
an
d s
tats
:
X-U
n-e
rup
ted
:
1-P
arti
ally
eru
pte
d:
2-S
eale
d B
efo
re a
nd
So
un
d:
3-S
ou
nd
an
d s
eale
d n
ow
:
4-E
arly
les
ion
an
d s
eale
d n
ow
:
5-R
esea
led
no
w:
6-S
ou
nd
bu
t n
ot
seal
ed(R
easo
n):
7-
Dec
ayed
an
d r
efer
red
:
8-
Oth
ers:
Op
era
tor:
Da
te:
Co
mm
ents
:……
……
……
……
……
……
To
oth
#
C
od
es
17
X
1
2
3
4
5
6
7
8
16
X
1
2
3
4
5
6
7
8
15
X
1
2
3
4
5
6
7
8
14
X
1
2
3
4
5
6
7
8
24
X
1
2
3
4
5
6
7
8
25
X
1
2
3
4
5
6
7
8
26
X
1
2
3
4
5
6
7
8
27
X
1
2
3
4
5
6
7
8
37
X
1
2
3
4
5
6
7
8
36
X
1
2
3
4
5
6
7
8
35
X
1
2
3
4
5
6
7
8
34
X
1
2
3
4
5
6
7
8
44
X
1
2
3
4
5
6
7
8
45
X
1
2
3
4
5
6
7
8
46
X
1
2
3
4
5
6
7
8
47
X
1
2
3
4
5
6
7
8
Flu
ori
de
1stA
pp
lica
tio
n(D
ate)
:
Flu
ori
de
2n
dA
pp
lica
tio
n(D
ate)
:
(Giv
e re
aso
n i
f n
ot
app
lied
)
Pit
an
d F
issu
re S
ea
lan
ts (
Ro
un
d o
ff
Ap
pro
pri
ate
cod
es)
Co
des
an
d s
tats
:
X-U
n-e
rup
ted
:
1-P
arti
ally
eru
pte
d:
2-S
eale
d B
efo
re a
nd
So
un
d:
3-S
ou
nd
an
d s
eale
d n
ow
:
4-E
arly
les
ion
an
d s
eale
d n
ow
:
5-R
esea
led
no
w:
6-S
ou
nd
bu
t n
ot
seal
ed(R
easo
n):
7-
Dec
ayed
an
d r
efer
red
:
8-
Oth
ers:
Op
era
tor:
Da
te:
Co
mm
ents
:……
……
……
……
……
……
……
…
To
oth
#
C
od
es
17
X
1
2
3
4
5
6
7
8
16
X
1
2
3
4
5
6
7
8
15
X
1
2
3
4
5
6
7
8
14
X
1
2
3
4
5
6
7
8
24
X
1
2
3
4
5
6
7
8
25
X
1
2
3
4
5
6
7
8
26
X
1
2
3
4
5
6
7
8
27
X
1
2
3
4
5
6
7
8
37
X
1
2
3
4
5
6
7
8
36
X
1
2
3
4
5
6
7
8
35
X
1
2
3
4
5
6
7
8
34
X
1
2
3
4
5
6
7
8
44
X
1
2
3
4
5
6
7
8
45
X
1
2
3
4
5
6
7
8
46
X
1
2
3
4
5
6
7
8
47
X
1
2
3
4
5
6
7
8
Flu
ori
de
1stA
pp
lica
tio
n(D
ate)
:
Flu
ori
de
2n
dA
pp
lica
tio
n(D
ate)
:
(Giv
e re
aso
n i
f n
ot
app
lied
)
Pit
an
d F
issu
re S
ea
lan
ts (
Ro
un
d o
ff
Ap
pro
pri
ate
cod
es)
Co
des
an
d s
tats
:
X-U
n-e
rup
ted
:
1-P
arti
ally
eru
pte
d:
2-S
eale
d B
efo
re a
nd
So
un
d:
3-S
ou
nd
an
d s
eale
d n
ow
:
4-E
arly
les
ion
an
d s
eale
d n
ow
:
5-R
esea
led
no
w:
6-S
ou
nd
bu
t n
ot
seal
ed(R
easo
n):
7-
Dec
ayed
an
d r
efer
red
:
8-
Oth
ers:
Op
era
tor:
Da
te:
Co
mm
ents
:……
……
……
……
……
……
To
oth
#
C
od
es
17
X
1
2
3
4
5
6
7
8
16
X
1
2
3
4
5
6
7
8
15
X
1
2
3
4
5
6
7
8
14
X
1
2
3
4
5
6
7
8
24
X
1
2
3
4
5
6
7
8
25
X
1
2
3
4
5
6
7
8
26
X
1
2
3
4
5
6
7
8
27
X
1
2
3
4
5
6
7
8
37
X
1
2
3
4
5
6
7
8
36
X
1
2
3
4
5
6
7
8
35
X
1
2
3
4
5
6
7
8
34
X
1
2
3
4
5
6
7
8
44
X
1
2
3
4
5
6
7
8
45
X
1
2
3
4
5
6
7
8
46
X
1
2
3
4
5
6
7
8
47
X
1
2
3
4
5
6
7
8
160160
Forms usedin The Program
Sch
oo
l O
ra
l H
ea
lth
Pro
gra
m,
Ku
wa
it-F
orsy
th (
Inte
rmed
iate
Sch
oo
ls)
Pre
ven
tio
n C
ha
rt f
or
Mo
bil
e T
eam
s
Sch
ool
Nam
e a
nd
Co
de:
S
tud
ent
Na
me:
C
ivil
ID
:
P
rog
ram
:
6
th
Gra
de
7th
G
rad
e
8th
G
rad
e
9
th G
rad
e F
luo
rid
e 1
stA
pp
lica
tio
n(D
ate)
:
Flu
ori
de
2n
dA
pp
lica
tio
n(D
ate)
:
(Giv
e re
aso
n i
f n
ot
app
lied
)
Pit
an
d F
issu
re S
ea
lan
ts (
Ro
un
d o
ff
Ap
pro
pri
ate
cod
es)
Co
des
an
d s
tats
:
X-U
n-e
rup
ted
:
1-P
arti
ally
eru
pte
d:
2-S
eale
d B
efo
re a
nd
So
un
d:
3-S
ou
nd
an
d s
eale
d n
ow
:
4-E
arly
les
ion
an
d s
eale
d n
ow
:
5-R
esea
led
no
w:
6-S
ou
nd
bu
t n
ot
seal
ed(R
easo
n):
7-
Dec
ayed
an
d r
efer
red
:
8-
Oth
ers:
Op
era
tor:
Da
te:
Co
mm
ents
:……
……
……
……
……
……
To
oth
#
C
od
es
17
X
1
2
3
4
5
6
7
8
16
X
1
2
3
4
5
6
7
8
15
X
1
2
3
4
5
6
7
8
14
X
1
2
3
4
5
6
7
8
24
X
1
2
3
4
5
6
7
8
25
X
1
2
3
4
5
6
7
8
26
X
1
2
3
4
5
6
7
8
27
X
1
2
3
4
5
6
7
8
37
X
1
2
3
4
5
6
7
8
36
X
1
2
3
4
5
6
7
8
35
X
1
2
3
4
5
6
7
8
34
X
1
2
3
4
5
6
7
8
44
X
1
2
3
4
5
6
7
8
45
X
1
2
3
4
5
6
7
8
46
X
1
2
3
4
5
6
7
8
47
X
1
2
3
4
5
6
7
8
Flu
ori
de
1stA
pp
lica
tio
n(D
ate)
:
Flu
ori
de
2n
dA
pp
lica
tio
n(D
ate:
(Giv
e re
aso
n i
f n
ot
app
lied
)
Pit
an
d F
issu
re S
ea
lan
ts (
Ro
un
d o
ff
Ap
pro
pri
ate
cod
es)
Co
des
an
d s
tats
:
X-U
n-e
rup
ted
:
1-P
arti
ally
eru
pte
d:
2-S
eale
d B
efo
re a
nd
So
un
d:
3-S
ou
nd
an
d s
eale
d n
ow
:
4-E
arly
les
ion
an
d s
eale
d n
ow
:
5-R
esea
led
no
w:
6-S
ou
nd
bu
t n
ot
seal
ed(R
easo
n):
7-
Dec
ayed
an
d r
efer
red
:
8-
Oth
ers:
Op
era
tor:
Da
te:
Co
mm
ents
:……
……
……
……
……
……
To
oth
#
C
od
es
17
X
1
2
3
4
5
6
7
8
16
X
1
2
3
4
5
6
7
8
15
X
1
2
3
4
5
6
7
8
14
X
1
2
3
4
5
6
7
8
24
X
1
2
3
4
5
6
7
8
25
X
1
2
3
4
5
6
7
8
26
X
1
2
3
4
5
6
7
8
27
X
1
2
3
4
5
6
7
8
37
X
1
2
3
4
5
6
7
8
36
X
1
2
3
4
5
6
7
8
35
X
1
2
3
4
5
6
7
8
34
X
1
2
3
4
5
6
7
8
44
X
1
2
3
4
5
6
7
8
45
X
1
2
3
4
5
6
7
8
46
X
1
2
3
4
5
6
7
8
47
X
1
2
3
4
5
6
7
8
Flu
ori
de
1stA
pp
lica
tio
n(D
ate)
:
Flu
ori
de
2n
dA
pp
lica
tio
n(D
ate)
:
(Giv
e re
aso
n i
f n
ot
app
lied
)
Pit
an
d F
issu
re S
ea
lan
ts (
Ro
un
d o
ff
Ap
pro
pri
ate
cod
es)
Co
des
an
d s
tats
:
X-U
n-e
rup
ted
:
1-P
arti
ally
eru
pte
d:
2-S
eale
d B
efo
re a
nd
So
un
d:
3-S
ou
nd
an
d s
eale
d n
ow
:
4-E
arly
les
ion
an
d s
eale
d n
ow
:
5-R
esea
led
no
w:
6-S
ou
nd
bu
t n
ot
seal
ed(R
easo
n):
7-
Dec
ayed
an
d r
efer
red
:
8-
Oth
ers:
Op
era
tor:
Da
te:
Co
mm
ents
:……
……
……
……
……
……
To
oth
#
C
od
es
17
X
1
2
3
4
5
6
7
8
16
X
1
2
3
4
5
6
7
8
15
X
1
2
3
4
5
6
7
8
14
X
1
2
3
4
5
6
7
8
24
X
1
2
3
4
5
6
7
8
25
X
1
2
3
4
5
6
7
8
26
X
1
2
3
4
5
6
7
8
27
X
1
2
3
4
5
6
7
8
37
X
1
2
3
4
5
6
7
8
36
X
1
2
3
4
5
6
7
8
35
X
1
2
3
4
5
6
7
8
34
X
1
2
3
4
5
6
7
8
44
X
1
2
3
4
5
6
7
8
45
X
1
2
3
4
5
6
7
8
46
X
1
2
3
4
5
6
7
8
47
X
1
2
3
4
5
6
7
8
Flu
ori
de
1stA
pp
lica
tio
n(D
ate)
:
Flu
ori
de
2n
dA
pp
lica
tio
n(D
ate)
:
(Giv
e re
aso
n i
f n
ot
app
lied
)
Pit
an
d F
issu
re S
ea
lan
ts (
Ro
un
d o
ff
Ap
pro
pri
ate
cod
es)
Co
des
an
d s
tats
:
X-U
n-e
rup
ted
:
1-P
arti
ally
eru
pte
d:
2-S
eale
d B
efo
re a
nd
So
un
d:
3-S
ou
nd
an
d s
eale
d n
ow
:
4-E
arly
les
ion
an
d s
eale
d n
ow
:
5-R
esea
led
no
w:
6-S
ou
nd
bu
t n
ot
seal
ed(R
easo
n):
7-
Dec
ayed
an
d r
efer
red
:
8-
Oth
ers:
Op
era
tor:
Da
te:
Co
mm
ents
:……
……
……
……
……
……
To
oth
#
C
od
es
17
X
1
2
3
4
5
6
7
8
16
X
1
2
3
4
5
6
7
8
15
X
1
2
3
4
5
6
7
8
14
X
1
2
3
4
5
6
7
8
24
X
1
2
3
4
5
6
7
8
25
X
1
2
3
4
5
6
7
8
26
X
1
2
3
4
5
6
7
8
27
X
1
2
3
4
5
6
7
8
37
X
1
2
3
4
5
6
7
8
36
X
1
2
3
4
5
6
7
8
35
X
1
2
3
4
5
6
7
8
34
X
1
2
3
4
5
6
7
8
44
X
1
2
3
4
5
6
7
8
45
X
1
2
3
4
5
6
7
8
46
X
1
2
3
4
5
6
7
8
47
X
1
2
3
4
5
6
7
8
161161
