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TO PRINT THESE LABELS CORRECTLY, YOU MUST USE AVERY 5963 SHIPPING LABELS. E-MAIL [email protected] FOR HELP. Oral Health Assessment—Birth to 3 Years of Age Mother/caregiver’s oral health ___________________________ ___________________________ ___________________________ ___________________________ Does mother have a dentist? Yes Outcome No Education Oral Health Assessment—Birth to 3 Years of Age Existing dental home? Yes No caries staining plaque demineralization night feeding frequent snacking/juice intake (sippy cup) special needs SES Fluoride Referral Completed Mother/caregiver’s oral health ___________________________ ___________________________ ___________________________ ___________________________ Does mother have a dentist? Yes Outcome No Education © 2009, AAP Oral Health Initiative ___________________________ ___________________________ ___________________________ ___________________________ Does mother have a dentist? Yes Outcome No Education Existing dental home? Yes No caries staining plaque demineralization night feeding frequent snacking/juice intake (sippy cup) special needs SES Referral Completed Mother/caregiver’s oral health ___________________________ ___________________________ ___________________________ ___________________________ Does mother have a dentist? Yes Outcome No Education © 2009, AAP Oral Health Initiative ___________________________ ___________________________ ___________________________ ___________________________ Does mother have a dentist? Yes Outcome No Education Existing dental home? Yes No caries staining plaque demineralization night feeding frequent snacking/juice intake (sippy cup) special needs SES Fluoride Referral Completed Mother/caregiver’s oral health ___________________________ ___________________________ ___________________________ ___________________________ Does mother have a dentist? Yes Outcome ___________________________ ___________________________ ___________________________ Does mother have a dentist? Yes Outcome No Education Existing dental home? Yes No caries staining plaque demineralization night feeding frequent snacking/juice intake (sippy cup) special needs SES Fluoride Referral No Education Completed Mother/caregiver’s oral health ___________________________ ___________________________ ___________________________ ___________________________ Does mother have a dentist? Yes Outcome ___________________________ ___________________________ ___________________________ Does mother have a dentist? Yes Outcome No Education Existing dental home? Yes No caries staining plaque demineralization night feeding frequent snacking/juice intake (sippy cup) special needs SES Fluoride Referral © 2009, AAP Oral Health Initiative Fluoride Referral Completed Existing dental home? Yes No caries staining plaque demineralization night feeding frequent snacking/juice intake (sippy cup) special needs SES Fluoride Referral Completed No Education Existing dental home? Yes No caries staining plaque demineralization night feeding frequent snacking/juice intake (sippy cup) special needs SES Fluoride Referral Completed © 2009, AAP Oral Health Initiative Oral Health Assessment—Birth to 3 Years of Age ___________________________ No caries staining plaque demineralization night feeding frequent snacking/juice intake (sippy cup) special needs SES Oral Health Assessment—Birth to 3 Years of Age © 2009, AAP Oral Health Initiative Mother/caregiver’s oral health Yes © 2009, AAP Oral Health Initiative Oral Health Assessment—Birth to 3 Years of Age ___________________________ Existing dental home? Oral Health Assessment—Birth to 3 Years of Age © 2009, AAP Oral Health Initiative Mother/caregiver’s oral health Completed © 2009, AAP Oral Health Initiative Oral Health Assessment—Birth to 3 Years of Age Mother/caregiver’s oral health Referral Oral Health Assessment—Birth to 3 Years of Age Fluoride Fluoride © 2009, AAP Oral Health Initiative Oral Health Assessment—Birth to 3 Years of Age Mother/caregiver’s oral health Existing dental home? Yes No caries staining plaque demineralization night feeding frequent snacking/juice intake (sippy cup) special needs SES Completed Oral Health Assessment—Birth to 3 Years of Age Mother/caregiver’s oral health ___________________________ ___________________________ ___________________________ ___________________________ Does mother have a dentist? Yes Outcome No Education Existing dental home? Yes No caries staining plaque demineralization night feeding frequent snacking/juice intake (sippy cup) special needs SES Fluoride Referral © 2009, AAP Oral Health Initiative Completed
