Child Medical & Dental History Form
2020-2021 Academic Year
Homeroom Teacher: (Not Required)
Child's Name:(First, Middle, Last)
Child's Nickname: (Not Required)
Child's Date of Birth
Child's Race: (Select One)
American Indian/Alaska Native
More Than One Race
Parent/Guardian Name: (First, MI, Last)
Date of Birth:
Relationship To Student:
If Other, what relationship are you to the student?
We request family size and income information on all patients for governmental reporting purposes.
Number of people in your household:
Average Yearly Income for everyone in the household:
DENTAL INSURANCE INFORMATION
Do you have "Dental" insurance for your child (includes MEDICAID)?
If yes, complete the insurance information below:
We need your
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.
Dental Insurance Name:
Dental Insurance Address
Policy Holder's Name:
Policy Holder's Date of Birth:
Policy Holder's SS#:
MEDICAL INSURANCE INFORMATION
This information is
for the student’s health record to be complete but will
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
Policy Holder's Date of Birth:
Policy Holder's SS#
Your Child's Medical Provider's Name and Phone Number:
Is your child allergic to "LATEX"?
Please list any medication/food allergies:
Is your child currently taking any medications routinely:
” 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)
1. Do you have "well water" ?
Does your child use fluoride toothpaste?
2. How often does your child eat sugary foods/drinks? Examples are juice, soft drinks (pop), Kool-Aid, energy drinks, etc.
Only at mealtimes
Throughout the day
In bottle or sippy cup at bedtime
3. Is your child eligible for programs such as WIC, Head Start, Medicaid or KCHIP?
4. How long has it been since a member of your child’s family (mother, father, brothers, sisters) had a cavity?
In the last 6 months
Between 6 months and 23 months ago
More than 2 years ago
5. How often does your child see the dentist?
Every six months
Only when he/she has a toothache
Only with the "school dentist"
6. If you have a dentist that sees your child regularly, please provide the dentist’s name and address:
Please place a check in the box if your CHILD has any of the medical problems listed below: Check All That Apply
Diabetes Type 1
Diabetes Type 2
Blindness or Vision Loss
Please list any other illnesses that your child has that are not listed, or describe any current illness if needed:
Please list any surgeries that your child had, if any:
To your knowledge, does your child use tobacco or vape?
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.
HIGH BLOOD PRESSURE
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.
PARENT/GUARDIAN: TYPE YOUR FULL NAME:
REQUIRED: Use your mouse or touchscreen device to obatin signature below and click Submit Form.
****Once you click "
", please be patient. You will get a "
" message once complete!****