SUN Smiles Screening Data Form - Tapestry of Health

Staff Name*

First Last

Work Location County*

Screening Date*

WIC PID #*

Date of Birth*

Gender*

Female
Male

Race*

Hispanic/Latino*

Yes
No

Client Type:*

Pregnant
Postpartum
Child

County of Residence*

Preferred Spoken Language, if not English:*

Health Insurance:*

Medical Assistance
Private
Uninsured

Education Provided:*

Yes
No

Client Screening Questions

1. Are you (or your child) having any dental problems such as pain, difficulty chewing, sensitivity to hot or cold, bleeding gums, change in taste or loose teeth (except for baby teeth)?*

Note: Advise clients with urgent needs to go to the emergency room at the hospital if they feel their problem cannot wait or if they begin feeling worse.

Yes
No

Is there a regular dentist that you can go to?*

Yes
No (If No, referral to the CHW)

2. Have you (or your child over one year of age) been to the dentist in the last year (or since his/her first birthday)?*

Yes
No

2a. Do you have a regular dentist you see?*

Yes
No (If No, refer to CHW)

2b. Are you having any trouble getting an appointment, getting to the dentist or paying for the appointments?*

Yes (If Yes, refer to CHW)
No

3. Have you (or your child) been to the emergency department for a dental problem in the last year?*

Yes
No

For CHW Referral Only

If the screening indicates a need for referral to a CHW, the nutritionist will tell the client that -

We have people who can help you figure out how you (or your child) can see a dentist you can afford. Would it be okay if one of them called you?*

Yes
No

If Yes, complete the following information:

Client Name*

First Last

Parent/Guardian Name

Phone*

Texting OK?*

Yes
No

Best Contact Time:*

Notes