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Student Name: ___________________________________________ Birth Date ____________ Boy GirlFirst Middle LastID # ______________ Grade/Room ______________ School attended last year: ____________________Dear Parent/Guardian:A student’s health may affect his or her learning. Therefore, health information is important in planning for the student’s needs at school. Health information from this form may be shared with other school staff as needed. Please complete this form and return it to school as soon as possible.____________________________________________________________Licensed School Nurse Health Services Assistant or Licensed Practical Nurse PhoneSchool____________________________ School Year: ______________HEALTH CONCERNSPlease put a ? if the student has any of these health concerns:? No Health Concerns? ADHD/ADDAllergies (to what?) ____________________________________________________________________Asthma or other breathing problems ? Yes ? Noa. Has the student ever been diagnosed by a doctor as having asthma? ? Yes ? Nob. Has the student had episode(s) of wheezing (whistling in the chest) in the last 12 months? ? Yes ? Noc. In the last 12 months have you heard the student wheeze or cough after active playing? ? Yes ? Nod. Other breathing problem (describe) _____________________________________________________Bladder problems/ Bowel problems (describe) _______________________________________________Diabetes: ? Type 1 ? Type 2 Managed by: ? Diet only ? Oral meds ? Insulin injections ? Insulin pumpExposure to drugs and/or alcohol before birth________________________________________________Heart Problems (describe)________________________________________________________________Is the student pregnant? Due date ______ Does the student have children? Age of child(ren) _________Seizures: Type (describe) _______________________________Date of last seizure: _________________Social/emotional/behavioral/mental health concerns (describe) _________________________________Other health concern or significant history of problems (describe) _______________________________Activity restrictions: (describe) ____________________________________________________________Any recent surgeries or hospitalizations? Yes No If yes, explain._____________________________________________________________________________________EMERGENCIES: Does the student have a health problem that could result in an emergency? Yes NoIf yes, describe: _____________________________________________________________________________________________________________________________________________________________MEDICATIONS: List ALL medications that the student takes every day or when needed. Consent is REQUIRED for ALL medication taken at school, including over the counter medications. The consent must be signed by both HEALTH CARE PROVIDER and PARENT. A new consent is needed each school year. Forms are available in the health office. Medication Name Purpose Dose How often taken?________________________________________________________________________________________________________________________________________________________________This health information may be shared with MPS school staff as needed. If you do not want this healthinformation shared, please contact the school nurse __________________________________at _________________ School Nurse Name Phone/PagerParent/Guardian signature: ______________________________ Daytime phone __________________Print Parent/Guardian name: ________________________________________ Date: _______________Parent/Guardian e-mail contact: ______________________________________HAS THE PATIENT SEEN THE DENTIST IN THE LAST YEAR? YES NOApproximate date of last dental visit: _______________ Date of last x-rays_______________ Name of Clinic ______________________________________INSURANCE INFORMATION:1. Does the patient have insurance through the state? Yes No If yes, what is the member ID number (PMI) ______2. Does the patient have Assured Access through Hennepin County? ¨Yes ¨No If yes, what is the client ID: FPG%: Expiration date: 3. Does the patient have private insurance through a parent’s employer? Yes No If yes, fill in information below:Name of Dental Insurance ____________________________Phone # ________________________Policy Holder’s Name/Name of Employee __________________ Date of birth_____________________Dental Plan Identification Number or Social Security # _____________________________Children’s Dental Services Authorization for Dental Exam and Treatment: I give permission for CDS to provide a dental exam, preventive services, and required restorative care (dental treatment). Specifically I consent to routine dental treatments being performed on my child, including examinations, x-rays, cleanings, fluoride, and sealants. I understand that CDS staff may be in contact with me to obtain additional informed consent to provide restorative procedures such as fillings, crowns, extractions and other treatments if needed. I understand that with any procedure there are associated risks, but that these risks are often outweighed by the benefits of such treatment. Risks of not having treatment done include the following:Tooth ache, infection, or dental abscess that may cause pain, fever, swelling, and/or spread of infection to other parts of the body that can lead to potentially life-threatening complications.2.Difficulty chewing and/or maintaining good nutrition.3.Gum inflammation and/or development of cyst in gum tissue.5.Facial swelling and/or possible loss of teeth.6.Tooth sensitivity to hot or cold.7.Ongoing pain, bad breath, unpleasant taste in mouth and difficulty opening mouth.I also understand that while rare, there are certain inherent and potential risks in any treatment plan or procedure, and that such operative risks include but are not limited to the following:1.Occasional bleeding of the gums that can last up to 12 hours.2.Swelling of the face or pain or jaw stiffness that can last for several days.3.Injury to adjacent teeth, tissue, or fillings.4.Fracture of the jaw and necessity to surgically treat the fracture.5.Injury to the nerve underlying the lower teeth, resulting in numbness, tingling, pain, or other sensory disturbances to the lip, cheek, chin, gums, teeth, and tongue.6.Unexpected reaction to the anesthetic.7.Infection in the tooth socket that can be painful, tender, and swollen if a permanent tooth is extracted.8.Biting lip while still numb.I give permission for CDS to bill my insurance for any services provided to the individual listed for care and I understand that I am responsible for any amount not covered by the insurance. I give my permission for CDS to share the patient’s oral health information with the school, to provide the most comprehensive care possible. This consent form is valid for one year from the date signed unless revoked in writing to CDS. If I had any further questions about the risks and benefits of treatment or alternate treatment options I have contacted a provider at CDS to ask such questions and they have been answered adequately. I have had adequate time to make the decision to give consent freely. The medical history provided is accurate to the best of my knowledge. If my medical history changes I will inform CDS. Signing below also authorizes release of records as needed for treatment.___________________________________________________________________Parent/Guardian (or patients 18 years of age or older)Signature Date**Please note: If you or your child is seen by one of CDS' hygienists this does not take the place of an exam; we recommend a full examination with the dentist within 6 months if he/she has not already done so.I understand that the Minneapolis Public Schools Health Center can provide health services for students: I consent to the following services for my child:____ I consent for my child to receive medical care including physical exams, drawing blood, vaccinations, and referrals.____I consent to my child receiving counseling services, including on-on-one counseling, insurance assistance and coordination of outside resources and/or services)___________________________________________________________________Parent/Guardian (or patients 18 years of age or older)Signature Date ................
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