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AJCHS District #81 Medical Information Form
Please complete the following required information for our Health Center.
32
Questions
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HIPAA
Compliance
1
Legal Name of Student
*
This field is required.
First Name
Last Name
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2
Student Date of Birth
*
This field is required.
-
Date
Month
Day
Year
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3
Student's Grade Level
*
This field is required.
9th
10th
11th
12th
9th
10th
11th
12th
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4
Illinois law requires students entering their senior year of high school to have 2 meningococcal (meningitis) vaccines. If your student has already had these vaccines and you have a record of it, you may take a picture of it here. If not, please skip to the next page and bring your student's immunization record to registration.
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5
Illinois law requires students entering 9th grade to have an up-to-date physical on file with their school. Please complete a physical (with immunization records) with your student's doctor and return to the school nurse at registration.
Form attached for your convenience.
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6
If you already have a 9th grade physical and a copy of your student's updated immunizations, you can upload the file here, or skip to the next page to take a picture
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7
If you already have your student's 9th grade physical and updated immunizations, you can take a picture of them to upload here, or skip to the next page.
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8
Illinois law (Child Health Examination Code, 77 Ill. Adm. Code 665) states all children in kindergarten and the second, sixth and ninth grades of any public, private or parochial school shall have a dental examination. The examination must have taken place within 18 months prior to May 15 of the school year. A licensed dentist must complete the examination, sign and date this Proof of School Dental Examination Form.
Form attached for your convenience.
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9
If you already have your student's 9th grade dental exam completed, you may upload it here, OR you can skip to the next page and take a photo of the document.
Drag and drop files here
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Max. file size
: 10.6MB
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10
If you already have your student's 9th grade dental exam completed, you may upload a photo here, or skip to the next page.
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11
Student's Physician (Name, City, State)
*
This field is required.
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12
Medications taken at home
This information is useful to us in the event of a medical emergency to ensure that emergency responders are given immediate, accurate information to provide the best care possible for your student. This information is confidential.
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13
Does your student have any medications that need to be taken at school, and/or would you like your student to be able to receive medications such as Tylenol or antacids from the school nurse?
*
This field is required.
YES
NO
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14
This form must be completed by your student's doctor and returned to the nurse in order for the nurse to distribute ANY medication to your child at school.
Students may not receive any medications (including things like Tylenol or antacids) without this form on file.
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15
Would you like your student to have access to the SIU Family Medicine Care-A-Van?
*
This field is required.
This mobile health clinic visits AJ weekly and provides services such as 1) care for acute and chronic health conditions, 2) school and sports physicals, 3) treating sports and other minor injuries, and 4) renewing or prescribing medications. No payment is required at time of treatment, and services will be billed to private and state insurance plans.
YES
NO
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16
Please complete this form to allow your student to have access to the SIU Family Medicine Care-A-Van. Return completed forms to the school nurse.
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17
Would you like your student to have access to Dental Safari at school?
*
This field is required.
Dental Safari is a mobile dental corporation staffed by a fully licensed dentist and staff. They provide cleanings, flouride treatments, and sealants as needed for students. Their services can be billed to medicaid, private insurance, or self-paid.
YES
NO
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18
If you would like your student to receive dental services through Dental Safari, please complete this form and return to the school nurse.
Alternately, you may complete the online form through Dental Safari's website here: https://secure.dentaleshare.com/patientform/6670-920/patient-form.html
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19
Does your student have asthma?
*
This field is required.
YES
NO
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20
Illinois requires schools to have an asthma action plan on file for any student with asthma. This plan must be updated annually. Please have your student's physician assist you in completing the action plan and return to the school nurse at registration.
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21
Does your student have diabetes?
*
This field is required.
YES
NO
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22
Illinois requires schools to have a diabetes management plan on file for each student with diabetes. These plans must be updated annually. Please complete this form with the assistance of your student's physician and return to the school nurse at registration.
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23
Does your student have allergies that may need to be treated at school?
*
This field is required.
For example, a food or insect allergy that requires your student to have an epi pen, or severe environmental allergies which require the use of antihistamines that may need to be given at school.
YES
NO
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24
Please complete this form with the assistance of your student's physician and return to the school nurse at registration.
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25
Does your student have seizures?
*
This field is required.
YES
NO
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26
Please describe your student's seizure condition, including information regarding medications and instructions for handling seizures at school.
The school nurse may follow up with you for a more detailed action plan to enable us to provide the best possible care for your student.
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27
Does your student have any dietary restrictions?
*
This field is required.
YES
NO
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28
Please describe your student's dietary restrictions.
Note that these restrictions will be communicated as foods for the student to avoid. Students on special diets (eg vegan, kosher) or with severe food allergies to dairy, wheat/gluten, or nuts should plan to bring their own food from home, as AJCHS cannot guarantee a contaminate-free kitchen.
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29
Does your student have any diagnosed mental health conditions?
*
This field is required.
In accordance with HIPPA standards, this information is confidential and will only be accessible to the school nurse. Knowledge of mental health conditions helps the nurse to have a complete picture of your student and enables her to provide the best possible care.
YES
NO
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30
Who is your student's mental health provider? (behavioral health professional, psychiatrist, and/or mental health therapist/counselor)
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31
Please list your student's mental health conditions, including medications (if applicable).
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32
Signature
By signing this form, you indicate that the information provided is correct.
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