2015-2016 Registration Memphis - Elem - Health Room - English

8/16/2019 2015-2016 Registration Memphis - Elem - Health Room - English

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© 2015 Well Child, Inc. This document may not

Every child needs t

Through its partnership with Well CChild has performed preventative h

identify many hidden health issues t

This packet includes consent forms

• A Physical Health Exam a• A Comprehensive Vision

Well Child is committed to improvingtaken advantage of these services.Health Care Community Plan, Tenn-Aetna. These services are at no co

You will be made aware of all findin

to have further health evaluation.

Please complete the following forms

SCS School-

1. Northside High School, 1212 Vo

2. Sheffield Career & TechnologyChuck Ave.

A community’s highest

children. If we do

be used, duplicated or published without the express, leg

e opportunity for healthy de

hild, your school district brings health caralth exams in schools for over 10 years a

at needed medical attention.

for two types of exams:

ndxam.

the health of children and tens of thousanell Child is able to bill to the following insu

Care Select, BlueCare, CoverKids, Amerigt to you, to the school or to the district.

s and given information about any recomm

(including signing the consents) and return

ased Health Clinics - 901-531-632

llintine 3. Westwood High School,

tr, 4350 4. East High School, 3206

ommitment is to the health and ed

not do both we will not accomplis

TM

1/27/2015

al consent of Well Child, Inc.

elopment.

to the schools. Weld has helped parents

s of parents haverance carriers: Unitedoup, Cigna, and

endation for your child

to the school.

1

480 Westmont

oplar Ave.

ucation of its

either.Journal of School Health

MemphisElementaryHealth Room


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© 2015 Well Child, Inc. This document may not be used, duplicated or published without the express, legal consent of Well Child, Inc.

(mm/dd/yyyy) / /

CONSENT/REGISTRATIONIt is very important that you complete every question

Name of School _______________________ Grade ____ Section ____ Teacher _____________

CHILD’S NAME – PLEASE PRINT CHILD’S SOCIAL SECURITY NUMBER Last Name, First Name M.I.

ADDRESS RACE: Black or African Amer. WhiteHispanic Asian Other

CITY STATE ZIP CODE

SEX Male Female AGE __________ DATE OF BIRTH

NAME OF CHILD’S DOCTOR OR CLINIC ______________________________________________ Name of Insurance Carrier (Please circle one): UnitedHealthCare, Tenn-Care Select, BlueCare, Amerigroup Tenn-Care Member ID:__________________ CoverKids, Cigna, Aetna, No Insurance, Other:_____________

Well Child will bill your insurance carrier or managed care organization for this physical examPrivate Insurance: Carrier: ________________ Policy #: _________________ Group#: ______________Policy Holder: Name: ______________________ Birth Date:_____________________

PARENT OR GUARDIAN’S INFORMATIONRESPONSIBLE PARTY’S NAME: RELATIONSHIP TO CHILD

HOME PHONE NUMBER WORK PHONE NUMBER *CELL NUMBER( ) __ __ __ - __ __ __ __ ( )__ __ __ - __ __ __ __ ( )__ __ __ - __ __ __ __

I consent to receive notifications by text message.

E-MAIL ADDRESS: _______________________________________ To receive child’s exam result.

PRIMARY LANGUAGE SPOKEN AT HOME ___________________________

FRIEND OR RELATIVE WHO WE CAN CONTACT IN CASE OF EMERGENCY AND SHARE MEDICAL INFORMATION

NAME________________________RELATIONSHIP_______________PHONE (_____)_______________

NAME________________________RELATIONSHIP_______________PHONE (_____)_______________

A Well Child exam is the same as in most doctor’s offices and includes the following procedures:1. Listen to the heart and lungs; 2. Feel and listen to the stomach; 3. Check the back for scoliosis (curve of the spine);4. Examine the skin for problems such as rashes or infections 5. Assess stages of development

A Board Certified Provider will conduct the Well Child exam behind a privacy screen. During the exam, clothes will belifted but not removed.

PARENTAL/GUARDIAN CONSENT AND ACKNOWLEGMENT: Notice of Privacy Practices is available at: www.wellchild.comI authorized my child to receive the annual physical exam conducted by Well Child. I have been notified of WelChild’s privacy practices. I authorize Well Child to send screening results home with my child in a sealedenvelope, to release information to my insurance carrier in order to process payment claims and to receivepayment of medical benefits for services rendered. For purposes of treatment and referral, I authorized releaseof medical information to the Health Department, the school system and my child’s physician/primary careprovider. I give permission to the school district to release my child’s immunization (shot) record for review byWell Child. This consent and authorization is effective until revoked by me.

*Date: Parent/Guardian Signature X

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HISTORY

Child’s Name: ______________________________________ SSN: ________________________

1. Current Medicines: List Over-the-counter & Prescription medicine: NO MEDICATIONS:

2. Current Treatment: Please check below any service your child is currently receiving:

Development (motor skills/learning): Speech/Language: Vision (glasses or contacts):

3. Exercise / Elimination: Answer Yes with an☑

Does your child eat meat?

Is your child's appetite? Good: Average: Picky:

Child’s bowel movements: Normal: Diarrhea: # days_____ Hard: # days____

How many days a week does your child exercise more than 30 minutes? 0–3 days: 4 days+:

4. Child’s Health History Has your child ever had any of the following? Answer Yes with an☑

NO TO ALL Cancer Heart murmur PE tubes in ears

Acne/Skin Problem Chicken Pox Liver trouble Seizures

ADHD/ADD Diabetes/sugar Mumps Sickle cell Trait

Anemia Ear infections Navel Hernia Sickle cell Disease

Asthma Eczema Passed out withexercise:

Sinus congestion

Autism Headaches Thyroid problems

Bronchitis Other:

5 a Asthma, if Yes above: How many times has 5 b Asthma, if Yes above: How often does your

your child been in a hospital or emergency room with child need to use the inhaler because of wheezing?

an asthma attack in the past 6 months? Per Week Per Month Per Year

6. GIRLS: Started Period: Month_________ Year___________ Heavy Bleeding?

7. Surgeries or Hospitalizations? Answer Yes with an ☑ : If yes, explain and give dates:

8. Immunizations (shots) up to date? Yes: No: Do Not Know:

9. Developmental History: Answer Yes with an ☑ : NO TO ALL DEVELOPMENTAL DELAYS:

Did your child have any delays in: i. Learning ii. Walking iii. Talking

10 Family History: Answer Yes with an ☑ : NO TO ALL FAMILY MEDICAL HISTORY PROBLEMS

Asthma/Lung disease High blood pressure Mental illness

Diabetes/Sugar High cholesterol StrokeHeart Trouble: Liver disease Sickle Cell:

11 Social/Socioeconomic History Answer Yes with an ☑ ☑☑

☑

Number of children at home? Anyone smoke in the home? A working smoke alarm?

Does child wear a seat belt? Are you a single parent? Child have problems in school?

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RISK ASSESSMENT QUESTIONNAIREChild’s Name: _________________________________________________________

Tuberculosis: A YES or NOT SURE answer may result in a referral to see your PCP or the HealthDepartment for further testing.

1 Child has been in close contact with a person with infectious tuberculosis?

2 Child has HIV infection or considered at risk for HIV Infection?

3 Child has contact with the any of the following: HIV infected, homeless, nursing home,institutionalized individuals, illicit drug users, or migrant farm workers?

4 Child has a poor immune system because of disease or treatment of disease?

5 Child was born in Asia, Africa or Latin America, a refugee, or an immigrant?

6 Child had an abnormal skin reaction (redness/swelling) to a TB skin test before

7 Child has had the disease of tuberculosis (TB) ?

Lead – Children 12 months through 5 years ONLY. – A “Yes” or “Unsure” answer may result in areferral to see your PCP or Health Department for testing.

8 Does your child live in or regularly visit a house/apartment built before 1950?

9 Does your child live in or visit a house/build before 1978 with recent ongoing repairs?

10 Has your child been seen eating paint chips, crayons, or soil/dirt?

Allergies: Answer Yes with an ☑ : NO TO ALL ALLERGIES:Medicines Amoxicillin Penicillin Other: ____________________

Food Peanuts Shellfish Other: ____________________

Environment Dirt/Dust Grass/Pollen Other: ____________________

PEDIATRIC SYMPTOM CHECKLIST 17 (PSC-17)Emotional and physical health go together in children. Because parents are often the first to notice a problem with their child’sbehavior, emotions, or learning, you can help your child get the best care possible by answering the following questions. Pleaseindicate which statement best describes your child.

Please mark under the heading that best describes your child:

Never (0) Sometime (1) Often (2

1 Fidgety, unable to sit still

2 Feels sad, unhappy

3 Daydreams too much

4 Refuses to share

5 Does not understand other people’s feelings

6 Feels hopeless

7 Has trouble concentrating

8 Fights with other children

9 Is down on him or herself

10 Blames others for his/her troubles

11 Seems to be having less fun

12 Does not listen to rules

13 Acts as if driven by a motor

14 Teases others

15 Worries a lot

16 Takes things that do not belong to him/her

17 Distracted easily

Comments: Totals:

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WELL CHILDHealth Services Survey

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Clinic / Health Room Treatment Consent

Child’s name: ________________ Date of birth: _______ SSN: __

Usual doctor: _________________ Sex: ____M ____ F Insurance ID # ___ _ __

I have read this Treatment Consent form and understand the health services available through the school-

based Health Room. I consent to all of the following:

• The above named student/patient may receive all services listed below at any of the Regional Clinics and/or in

the school-based Health Room.

• (Well Child) may exchange health care information with third party payers or other insurers for the purpose of

receiving payment for services and continuation of care.

• Both Well Child and my child’s primary care physician may exchange health care information for the purpose of

continuity and coordination of care

• Well Child may obtain a copy of the above named student’s/patient’s immunization record from the

student’s/patient’s school office, primary care provider’s office, and/or local health department

• Well Child may obtain a copy of the student’s information from the school district for healthcare purposes.

Services provided through the School-Based Health Room

Please check any of the following services which you DO NOT WANT provided to students/patients:

___ Decline Treatment for acute and chronicillness and injuries

___ Decline Mental health education, assessmentcounseling and referrals

___ Decline Nutrition, Education andCounseling

___ Decline Obesity screening and education

___ Decline Basic laboratory services andtests

___ Decline Administration of medication

___ Decline Individual, group, family andcommunity education

___ Decline Nursing care for chronic illnesses

By signing this form, I certify that I am the parent/legal guardian of the student/patient named above. Consent is

given for the above indicated services to be provided by Well Child within the capability of the licensure authority of

Well Child’s staff and the capability and capacity of the school-based Health Room. For any services outside the

capability or capacity of either Well Child or the school-based Health Room, the student/patient shall be referred to

an appropriate primary care service provider, or, if necessary, dispatch of emergency responders. I understand that

signing this form will allow my child to receive services from the school-based Health Room for all the years they

are enrolled in the school district. I understand that current Tennessee law allows for certain confidential medicalservices to minors without parental consent. I understand that I may withdraw my consent for services, in writing, a

any time.

The Notice of Privacy Practices and further information about the Regional Clinics and the school-based health

rooms can be accessed at: www.wellchild.com and in each clinic location.

X __________________________ X __________________________ ___________ Signature of patient Signature of parent/guardian Date


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Well Child provides eye servi

If your child needs vision servto receive an eye exam or renew hisinsurance and there will be no out of

Well Child will provide two paglasses. One pair, which may be coA SECOND PAIR of GLASSES will

Please complete the attach

Child’s first name: ____________ Date of Birth:________________

Phone number:_______-_______-

AUTHORIZATION FOR VISION AS

I authorize the performance of optostaff doctors. I acknowledge that aneducational purposes, provided thatfurther grant permission to release iclaims and for Well Child to receive

If you want this service for yourfollowing page of medical history

• Pupil dilation is using eye droinner eye health. Dilation caabout 2 hours.

• To ensure my child’s eye h ___ I authorize pupil dilati ___ I will schedule pupil di

Parent/legal guardian sign here:

Please call Well Child i

Page 1 of 2


ces and eyeglasses to students in the scho

ices, or has failed their school vision scree /her prescription for glasses in their school.

pocket expense to you.

irs of glasses for each elementary grade st vered by your healthcare plan, is for everyd

be provided, at no cost to you, and will be

d forms and return them to your child’s

___ Child’s last name: __________

chool name:______________________

________

SESSMENT AND TREATMENT

etry examinations, treatments, and/or refey information obtained from this examinatioindividual identities, rights and liberties willformation to my insurance carrier in order

payment of medical benefits for services re

hild please complete the information be.

ps to make the pupil larger to help the doctinclude some sensitivity to light and mild b

alth is normal: nlation at a later date

_____________________________ Dat

you have questions or want to be present for the e

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ols.

ing, he/she is eligibleThe exam is billed to

udent it prescribesay use to take home.ept at school.

school.

_______________

_______________

rrals by Well Childn may be used forbe protected. Io process paymentndered.

low and the

rs examine thelurred vision for

: ___________

am


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PLEASE DETACH THIS PAGE AND KEEP FOR YOUR RECORDS

The Physical Health Exam (EPSDT) includes the following:

1. A comprehensive history, including developmental/behavioral screenings. If you need helpwith these forms, please call toll free 1-866-403-5858.

2. Developmental Screenings. The Board Certified Provider will assess for normaldevelopment of language, behavioral/emotional, memory, behavioral/emotional, perceptionsand motor functions.

3. Vision and hearing screenings

4. A complete head-to-toe physical exam (your child will remain clothed, but clothes will belifted during the exam – see page two for explanation).

5. Immunization review. Parents must give signed consent for release of immunization record(shot record) to be reviewed by Well Child staff. We will follow up with you if immunizationsare needed.

6. Lab (blood work) is collected from a finger stick and lab will be completed: (a) at the agesshown below or, (b) when requested by parents/guardians or, (c) when medically necessary.

Hematocrit (Iron): 5 & 6 year olds, thirteen year olds, and others whenmedically necessary

Lead: Five year olds and younger when medicallynecessary

Glucose or Hemoglobin A1C(Sugar): Children identified when medically necessary

Urine: Children identified when medically necessary

The Comprehensive Optometry exam includes the following:

1. A Licensed Optometrist conducts all examinations.

2. Meets all standards for an annual eye exam per TennCare guidelines.

3. Will determine the acuity of vision and health of the eye.

4. Child's eyes may be dilated based on parental permission and clinical need.

5. Glasses will be prescribed and provided when necessary. They will be fitted to yourstudent at their school about three weeks after the exam.

These physical health and eye exams are the same as an annual visit to a primary provider oroptometrist. Please be aware that TennCare, Private/Commercial insurances and CoverKids will payfor only one of each of these exams per year, so if you are seeing your PCP or family optometrist,please continue to do so.

For information about Well Child’s Privacy Practices, please visit www.wellchild.com.

Contact us at 901-728-5858, or, 1-866-403-5858, if you would like to be present for the exam(s).

2015-2016 Registration Memphis - Elem - Health Room - English

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