New Cambria R-IV Student Health History & Dental Form

New Cambria R-IV Student Health History & Dental Screenings Form

2025-2026
Student's Name*

First NameLast Name
Student's Birthday*

MonthDayYear
Date
Student's Age*
Current Grade*
Teacher's Name*
Gender*

MaleFemale
Race*
Ethnicity*

Not Hispanic or LatinoHispanic or Latino
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
MOTHER'S Name*
Mother's Phone Number*
Please enter a valid phone number.
Email
example@example.com
Does child live with mother?*

YesNo
FATHER'S Name: *
Father's Phone Number*
Please enter a valid phone number.
Email
example@example.com
Does child live with father?*

YesNo
Emergency Contact Name #1 (OTHER THAN PARENTS)*
Emergency Contact #1 Phone Number*
Please enter a valid phone number.
Emergency Contact #1 Relationship to Student*
Emergency Contact Name # 2 (OTHER THAN PARENTS)*
Emergency Contact #2 Phone Number*
Please enter a valid phone number.
Emergency Contact #2 Relationship to Student*
Primary Doctor's Name*
Primary Doctor's Phone Number*
Dentist's Name*
Dentist's Phone Number*
Please check if your child has any of the following insurances*

Health InsuranceDental InsuranceVision InsuranceNone of these
Has your child received any immunizations since last school year?*

Yes: Please send documentation to update their fileNo

Does your child have any of the following conditions?*

	No	Yes	If yes, please explain (type/medications/treatment)
Food Allergy
Bee sting allergy
Seasonal/environmental allergy
Asthma?
ADD/ADHD
Diabetes (specify T1 or T2)
Seizures (date of last known seizure)
Heart condition
Mental health condition
Doctor ordered special diet

*If EpiPen is prescribed for any allergy, we WILL need an Allergy Action Plan.

*If inhaler will be used at school or asthma is Moderate or Severe, we WILL need a current Asthma Action Plan.
Is your child taking routine medications at this time?*

YesNo
Will prescribed medications be required during school hours per Doctor's order?

YesNo
Please list child's medications and the reason for taking them. If none, please put none. *
State law indicates no medications are to be given the first or last hour of school; Special circumstances will have to have prior approval. Listed below are some of the temporary medications available at the school if a minor illness occurs. They may be administered by the nurse or a trained staff member. The medications may be generic or name brand and dosage will be determined by the manufacturer's label. Please mark yes or no for each medication listed below:

Medication/Uses*

	Yes	No
Tylenol: mild pain, fever, headache
Ibuprofen: minor aches and pains, toothache, fever
Benadryl: allergy symptoms, itchy or runny nose, sneezing, hives, insect bites, rash, etc.
Claritin/Zyrtec: (nondrowsy) allergy symptoms, itchy or runny nose, sneezing
Tums/Mylicon tablets: indigestion, sour stomach, gas
Cough drops: minor throat irritation/cough, (if requested more than 2 days in a row, parent will be notified)
Sore throat spray: minor throat irritation
Anbesol or Orajel: tooth or gum pain
Calamine or anti-itch lotion/cream: minor skin irritations, itching

By signing below, I give permission for my child to participate in the school health program (including screenings and medication administration). I also give permission for the Macon County Health Department and the school to exchange information regarding my child's immunization record. My signature allows my child's health concerns to be shared with appropriate staff on a need-to-know basis only.
Parent/Guardian Signature*

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In the event that my child is injured or becomes ill and/or needs medical attention for any reason and I cannot be contacted, this authorization will serve as my request and authority for school authorities to call an ambulance service for the purpose of conveying my child to the hospital, and I authorize any and all medical tratment provided to my child. I hereby authorize the school to provide to the attending physician, hospital, or clinic relevant data from my child's file deemed necessary for treatment. I fully understand that I shall be responsible for all costs of ambulance service and any medical care or treatment provided to my child. I also give permission for the sharing of health information with appropriate staff members and medical personnel when necessary for the wellbeing of my child.

In the event of an anaphylactic emergency, I authorize trained school personnel to administer pre-filled epinephrine (EpiPen) and/or Benadryl. I also authorize trained school personnel to administer first-aid to my child.
Parent/Guardian Signature*

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New Cambria R-IV School Dental Screenings

Dear parent/guardian,

Our school, Macon County Health Dept., Long Branch Dental, and the Missouri Department of Health and Senior Services Office of Dental Health are offering a FREE oral health program to help prevent tooth decay/cavities in students. This program is offered to ALL students in Missouri, including those who visit a dentist regularly. Every student at New Cambria R-IV will receive an oral screening. Only with consent, a thin coating of fluoride varnish will be applied to your child’s teeth to help stop tooth decay/cavities. The fluoride will be applied two times during the school year. Fluoride varnish is safe for use in preventing and reversing small areas of early tooth decay/cavities. There is no cost for the fluoride varnish treatments, but you must give your consent for your child to receive them.

Your child will receive a free toothbrush, toothpaste, and information on oral health on screening days.

*This service does not replace a regular dental check-up. It is recommended to visit a dentist at least once a year.

FIRST DENTAL SCREENING AT New Cambria R-IV: September 26, 2025
Please choose below whether or not your child participates in the fluoride varnish.

YES, I do want my child to receive two applications of fluoride varnish, spaced 3-6 months apart.No, I do not want my child to receive two applications of fluoride varnish.
Mark the option that applies to your child's dental insurance.

Medicaid/Missouri Managed CarePrivate InsuranceNoneUnknown
Parent/Guardian Signature

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New Cambria R-IV Student Health History & Dental Screenings Form