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 Child Medical & Dental History Form 
 2020-2021 Academic Year


 
CHILD'S INFORMATION
 
 
 

 
 



 
 PARENT/GUARDIAN INFORMATION
 
 
 
 
 
 
 
 
 
 
 
We request family size and income information on all patients for governmental reporting purposes.
 
 
 

 
 DENTAL INSURANCE INFORMATION
 If yes, complete the insurance information below:
 
 We need your DENTAL insurance information.  DENTAL insurance is usually a separate policy.  Most medical Insurance does not cover dental services.  Medicaid covers dental exam and cleaning 2 times per year for children.
 
 
 
 


 
 MEDICAL INSURANCE INFORMATION
 This information is REQUIRED for the student’s health record to be complete but will only be billed if services are provided by a BSHC provider and with your consent. School nurse visits are not billed to insurance.
 
 
 
 
 
 
 Insurance Subscriber Information
 
 
 
 
 
 


 
  MEDICATION ALLERGIES
 
 
 
  CURRENT MEDICATIONS
 
 If “yes” to the above question, please list any medications that your child is taking: We need the name of the medication, dosage and how often your child takes the medication. It is very important that you list all the information not just the name of the medication.
 Name of Medication
 
 Dosage: Such as "Milligrams(mg); Grames(gm); Milliliters(ml).  Check the medicine bottles.
 How Often Taken (such as: once a day, twice a day, three times a day, as needed)
 
 
 
 
 
 
 
 
 


 
 DENTAL HISTORY
 
 
 
 6.  If you have a dentist that sees your child regularly, please provide the dentist’s name and address:
 
 
 


 
  MEDICAL HISTORY
Please place a check in the box if your CHILD has any of the medical problems listed below: Check All That Apply
         
         
         
         
         
 
 
 

 


 
 CHILD'S FAMILY MEDICAL HISTORY
 Please place a check in the box if any of your child’s immediate family has had any of the problems listed below. 
 
 
 
 
 
 
 
 
 
 
 
 Other (Please list): Please write the problem on the line below and check the appropriate box:
 
 
 
 
 
 
 
 
 
 
 
 
 
 By signing this form, I do agree that the completed information is true to the best of my knowledge.
 
 REQUIRED:  Use your mouse or touchscreen device to obatin signature below and click Submit Form.
 

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 ****Once you click "SUBMIT FORM", please be patient.  You will get a "SUCCESS" message once complete!****