National Center on Health (NCH) Oral Health Forms

The Office of Head Start NCH oral health forms are important records of a pregnant woman’s or child’s dental visit. The forms provide information on dental home and current oral health status, and what oral health care services were delivered during the dental visit. These services include diagnostic and preventive services, counseling, restorative and emergency care, and referral to a specialist for care. The forms also record what oral health care services are needed and any information to share with others.

Head Start Oral Health Form—Children [PDF, 229KB]

Head Start Oral Health Form—Pregnant Women [PDF, 232KB]

Head Start Oral Health Form—Children and Pregnant Women [PDF, 249KB]

Sample provider letter [Docx, 16KB]

Frequently Asked Questions

Are we required to use the NCH forms?

Our Head Start program has a form that fulfills our needs. Do we need to fill out our form in addition to the NCH form?

Our Head Start program uses a state-mandated form. Do we need to use the NCH form in addition to the state-mandated form?

No, Head Start programs are not required to use the NCH forms. Each Head Start program establishes a system to document the health services a pregnant woman or child receives. Head Start staff may use any form that works best for their program.

Can I enter our Head Start program name and contact information electronically in the NCH forms?

The electronic form is designed for Head Start staff to enter information into specific fields in the form. Staff can customize the forms with the Head Start program’s name, mailing address, phone and fax numbers, and e-mail address.

For best results, download the forms to your computer and open them with Adobe Reader, which is available at no charge. Then you can customize the forms and save or print them.

How can I explain to oral health providers how to use the NCH forms?

A sample letter [Docx, 16KB] is available for Head Start staff to tailor to introduce the NCH forms to oral health providers.

Should a new NCH form be used for each visit?

Yes, each time a pregnant woman or child has a dental visit, an oral health provider should complete a new form.

Do oral health providers need to complete an NCH form for dental visits that have already occurred?

No, oral health providers do not need to complete a form for dental visits that have occurred. The forms are intended for use at future dental visits.

How can oral health providers enter information electronically in the NCH forms?

The electronic form is designed for oral health providers to enter information into specific fields in the form.

For best results, encourage oral health providers to use Adobe Reader, which is available at no charge, to enter information into the forms and to then save or print them.

Last Reviewed: January 2014

Last Updated: August 31, 2015