Child Medical & Dental History Form
2020-2021 Academic Year
CHILD'S INFORMATION
Current School:
Grade:
Homeroom Teacher: (Not Required)
Child's Name:(First, Middle, Last)
Child's Nickname: (Not Required)
Child's Date of Birth
Age:
Gender:
Male
Female
Child's SSN#
Child's Race: (Select One)
White
Black/African American
Asian
American Indian/Alaska Native
Pacific Islander
Native Hawaiian
More Than One Race
Child's Ethnicity
Hispanic
Not Hispanic
PARENT/GUARDIAN INFORMATION
Parent/Guardian Name: (First, MI, Last)
Date of Birth:
Parent/Guardian SS#
Relationship To Student:
Parent
Guardian
Foster Parent
Step Parent
If Other, what relationship are you to the student?
Mailing Address:
City
State
Zip Code
Home Phone:
Work Phone:
Cell Phone:
E-mail Address:
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)?
Yes
No
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.
Dental Insurance Name:
ID #:
Group#:
Dental Insurance Address
Policy Holder's Name:
Policy Holder's Date of Birth:
Policy Holder's SS#:
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.
Primary Insurance
ID#
Group#
Secondary Insurance
ID#
Group#
Insurance Subscriber Information
Name:
Phone:
Address:
Policy Holder's Date of Birth:
Policy Holder's SS#
Your Child's Medical Provider's Name and Phone Number:
MEDICATION ALLERGIES
Is your child allergic to "LATEX"?
Yes
No
Please list any medication/food allergies:
CURRENT MEDICATIONS
Is your child currently taking any medications routinely:
Yes
No
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)
Medication 1:
Medication 2:
Medication 3:
DENTAL HISTORY
1. Do you have "well water" ?
Yes
No
Does your child use fluoride toothpaste?
Yes
No
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?
Yes
No
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:
Dentist Name:
Dentist 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
No Problems
Anemia
Diabetes Type 1
Epilepsy
ADHD
Clotting Disorders
Diabetes Type 2
Seizures
Seasonal Allergies
Hemophilia
Congenital Anomaly
Mental Disability
Asthma
Blindness or Vision Loss
Malignancy/Cancer
Other
anxiety
Heart Murmur
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?
No
Yes
Uncertain
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.
DIABETES
HIGH BLOOD PRESSURE
CANCER
HEART DISEASE
Mother
Mother
Mother
Mother
Father
Father
Father
Father
Brother
Brother
Brother
Brother
Sister
Sister
Sister
Sister
Other (Please list):
Please write the problem on the line below and check the appropriate box:
Other 1:
Mother
Father
Brother
Sister
Other 2:
Mother
Father
Brother
Sister
Other 3:
Mother
Father
Brother
Sister
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.
Reset Signature
****Once you click "
SUBMIT FORM
", please be patient. You will get a "
SUCCESS
" message once complete!****