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Dowmload DA Form 8006, also known as Pediatric Dentistry Diagnostic Form. This is a form that is used by a pediatric dentist for examination. Once completed a treatment plan would be developed and the form will be placed into the patient record.

All caries are to be noted on SF 603.

How To Fill-In

Step 1 – Fill in blocks 1 through 4 as follows:

  • 1. Medical Alert
  • 2. Chief Complaint
  • 3. Age (years, months)
  • 4. Weight (Lbs/KG)

Step 2 -  This is the section that addresses the basic topical appearances inside the mouth. Complete this following examination and fill in the columns in the following blocks:

  • 5. Occlusion
  • 10. Crossbite:
  • 11. Abnormalities
  • 12. Soft Tissue
  • 13. Oral Hygiene
  • 14. Behavior Assessment
  • 15. FRANKL Behavior Scale
  • 16. Habits (make notes inside block)
  • 17. Facial Features
  • 18. Mandibular Plane
  • 19. Date TX Initiated (yyyy/mm/dd)
  • 20. Proposed Length
  • 21. Appliances in Use
  • 22. Other Observations, Comments
  • 23. Planned Treatment & Sequence of Accomplishment

Step 3 - This section provides very basic patient information. Complete blocks 24 through 27

  • 24. Prepared by (Signature & Title)
  • 25. Department/Service/Clinic
  • 26. Date (yyyy/mm/dd)
  • 27. Patient’s Identification – (For typed or written entries provide: Name – Last, First, Middle Initial – Grade – Date – Hospital or Medical Facility

Step 4 - This section provides a more in depth view of the patient’s mouth and bone structure. It also considers possibilities as to  what could be needed for the treatment plan considering the tooth size and bone structure. Complete Sections 28 through 34 to complete:

  • 28. Tooth Size
  • 29. Sum of widths of mandibular incisors
  • 30. Mandibular
  • 31. PROBABILITY CHART – 75% LEVEL

32. Approximate decrease in arch length due to mesial migration of the first permanent molars taking up “leeway space” during replacement of the deciduous molars by the bicuspids –

33. CEPHALOMETRICS A. TWEED ANALYSIS

  • B. STEINER ANALYSIS Ref. Norm

 

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