AFFINIA SCHOOL BASED MEDICAL TREATMENT CONSENT FORM

Child's Name*

First NameLast Name

Sex*

MaleFemale

Date of Birth*

Date

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

School*

Grade

Parent/Guardian Name*

First NameLast Name

Relationship*

Primary Phone Number*

Please enter a valid phone number.

Home Phone

Please enter a valid phone number.

Alternate Phone

Please enter a valid phone number.

Email Address

example@example.com

Language Spoken at home

Emergency Contact

First NameLast Name

Emergency Contact Relationship

Emergency Phone Number

Please enter a valid phone number.

Ethnicity

Hispanic or LatinoNon Hispanic or Latino

Race

Does your family participate in a Housing Assistance Program?

YesNo

Health history. Please check all that apply*

	Yes	No
Asthma
Anemia
Back problems
Behavioral Issues
Congenital Heart Defect
Dental problems
Diabetes
Ear infections (frequent)
Ear surgery
Eczema
Eye/vision problems
Eye surgery
Headaches (frequent)
Hearing problems
Heart murmur
High blood pressure
Kidney or liver problems
Lead poisoning
Mental Disorder
Pregnancy
Physical problems
Seizures/Epilepsy
Sickle Cell Disease
Other (describe below)

Please explain any of the above checks.

Does your child have an allergy to any of the following?*

If yes to any allergies, please explain and describe reaction.

Hospitalization date(s), please describe problem.

Surgery date(s), list reason for surgery.

Medications your child is taking (or "none")*

Is the child sick today?*

YesNoDon't know

Has the child had a serious reaction to a vaccine in the past?*

YesNoDon't know

In the past 3 months, has the child taken medications that affect the immune system such as prednisone, other steroids, or anticancer drugs: drugs for the treatment of rheumatoid arthritis, Crohn's disease, or psoriasis: or had radiation treatment?*

YesNoDon't know

Is the child pregnant or is there a chance she could become pregnant during the next month?*

YesNoDon't know

Has the child been vaccinated in the last 4 weeks:*

YesNoDon't know

Please comment on any concerns you have for your child.

Does your child have a medical doctor?*

YesNo

Name of provider-

Last time your child was seen by provider for a physical/well child exam-

Preferred pharmacy (if Nurse Practitioner feels your child would benefit from a prescription)*

Does your child have health insurance?*

YesNo

Missouri Medicaid/Mo Health Net? If yes, Plan or DCN#

List plan name and number if your child has other medical insurance

Medical Services: This may include completing pediatric comprehensive medical histories and/or physical examinations, sports physicals, immunizations (scheduled and CDC recommended age-appropriate vaccines will be administered), vision and hearing screenings, referrals for specialty care, diagnosing and treating acute and chronic medical problems, writing prescriptions for medications, lab testing and interpreting test results. In addition, a complete asthma check-up consisting of provider examination, spirometry, an asthma action plan, and completion of permission to carry/administer documentation for those students that qualify can be performed.

Parent/Legal Guardian Name*

Signature of Parent/Guardian/Legal Representative for permissions. Please note, this consent is valid for two years. I give permission for Affinia Healthcare School Based Team to provide services for my child. I give consent for Affinia to use and disclose my child's health information to people involved in my child's care, also including my child's regular doctor and school nurse. I give consent for payment of authorized insurance carriers to be made on my behalf of Affinia for any services furnished to my child.*

Date*

Date

Parent/Legal Guardian Signature. I have been informed of Affinia Healthcare's Notice of Privacy Practices. I am aware that I have a right to receive a written copy of Affinia Healthcare's Notice of Privacy Practices upon request.*

Does your child need a sports physical today?*

YesNo

Please answer to the best of your knowledge. Describe all "Yes" answers below.

	Yes	No
Do you have any concerns that you would like to discuss with your provider?
Has a provider ever denied or restricted your participation in sports for any reason?
Do you have any ongoing medical issues or recent illness?
Have you ever passed out or nearly passed out during or after exercise?
Have you ever had discomfort, pain, tightness, or pressure in your chest during exercise?
Does your heart ever race or skip beats (irregular beats) during exercise?
Has a doctor ever told you that you have any heart problems?
Has a doctor ever ordered a test for your heart? (For example, electrocardiography (ECG) or echocardiography?
Have you ever had a seizure?
Has any family member or relative died of heart problems or had an unexpected or unexplained sudden death before age 35 (including drowning or unexplained car crash)?
Does anyone in your family have a genetic heart problem such as hypertrophic cardiomyopathy (HCM), Marfan syndrome, arrhythmogenic right ventricular cardiomyopathy (ARVC), long QT syndrome (LQTS), short QT syndrome (SQTS), Brugada syndrome or catacholaminergic polymorphic ventricular tachycardia (CPVT)?
Has anyone in your family had a pacemaker or an implanted defibrillator before age 35?

BONE AND JOINT QUESTIONS (SPORTS PHYSICAL CONT'D)*

	YES	NO
Have you ever had a stress fracture or an injury to a bone, muscle, ligament, joint or tendon that caused you to miss a practice or game?
Do you have a bone, muscle, ligament or joint injury that bothers you?

MEDICAL QUESTIONS (SPORTS PHYSICAL CON'T)*

	YES	NO
Do you cough, wheeze, or have difficulty breathing during or after exercise?
Are you missing a kidney, eye, testicle (males), your spleen, or any other organ?
Do you have groin or testicle pain or a painful bulge or hernia in the groin area?
Do you have any recurring skin rashes or rashes that come and go, including herpes or methicillin-resistant Staphylococcus aureus (MRSA)?
Have you had a concussion or head injury that caused confusion, a prolonged headache or memory problems?
Have you ever had numbness, tingling, or weakness in your arms or legs, or been unable to move your arms or legs after being hit or falling?
Have you ever become ill while exercising in the heat?
Do you, or someone in your family, have sickle cell trait or disease?
Have you ever had, or do you have, any problems with your eyes or vision?
Do you worry about your weight?
Are you trying to, or has anyone recommended, that you gain or lose weight?
Are you on a special diet or do you avoid certain types of foods of food groups?
Have you ever had an eating disorder?

FEMALES ONLY

	YES	NO
Have you ever had a menstrual period?

How old were you when you had your first menstrual period?

When was your most recent menstrual period?

How many periods have you had in the last 12 months?

Please explain any "YES" answers here

I hereby state that, to the best of my knowledge, my answers to the questions on this form are complete and correct.

Signature of Parent(s) or Guardian:*

Signature of Athlete (student can sign at time of physical if desired)

Date*

Date

Thank you for completing this form. Once you hit SUBMIT, it will be sent to Affinia Healthcare and the school nurse will be notified that we have your consent on file. Your school nurse or Affinia will always notify you before any services are provided to your child. Feel free to call Affinia at 314-814-8565 with any questions.