1 / 9

PARENT INTERVIEW DOCUMENTS/OUTREACH

PARENT INTERVIEW DOCUMENTS/OUTREACH. RECORD OF STUDENT HEALTH HISTORY Student Number: / / / / / / / / Student Name: Last First MI Birthdate: / / /

odessa
Download Presentation

PARENT INTERVIEW DOCUMENTS/OUTREACH

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. PARENT INTERVIEW DOCUMENTS/OUTREACH

  2. RECORD OF STUDENT HEALTH HISTORY Student Number: / / / / / / / / Student Name: Last First MI Birthdate: / / / Please indicate with a check mark in the appropriate column whether the child has had the illnesses listed below.

  3. ESPEDIENTE DE LA SALUD MEDICA DEL ESTUDIANTE Numero del Estudiante: / / / / / / / / /Fecha de Nacimiento: / / Nombre del Estudiante:Apellido Primer NombreInicial En la columnaapropiadapor favor marque lasenfermedadesque ha tenido el estudiante.

  4. Parent Interview/ Entrevista de Padres de Familia • Student’s NameDate of Birth: / / / • Nombre de EstudianteFecha de Nacimiento: / / / • MSDR NumberNúmero del MSDR: • Does your child have a doctor? Yes No • ¿Tiene su hijo(a) un doctor? Si No • If yes, who? • Si surespuestaes Si, Quién es? • Has yourchildrecentlyhad a physicaleamination? • Name of doctor seenlastyear? • ¿Ha tenido su hijo(a) un examen físico recientemente? • Nombre del doctor que vio el año pasado? • Doesyourchildhave a dentist? Yes No • ¿Tiene su hijo(a) un dentista? Si No • If yes, who? • Name of dentistseenlastyear? • Si surespuestaes Si, Quién es? • Nombre del dentista que vio el año pasado • Has yourchildrecentlyhad a dental examination? (Within 6 monthsto 1 year) Yes No • ¿Ha tenido su hijo(a) un examen dental recientemente? (Entre seis meses a un año) Si No • Doesyourchildhave medical insurance? Yes No • ¿Tiene su hijo(1 seguro Médico/asequranza? Yes No • PrivateInsurance • Seguro Privado • Medicaid: Citizenor non-citizen) (ciudadano y no ciudadanos) • Children’sHealthInsuranceProgram (CHIPS) • Basic HealthProgram (ifstudentis 19 orolder) (si el estudiante es mayor de ó tiene 19 años) • Do youwantyourchildtohave a physicalexamination at schoolprovidedbythe Migrant Education Program at no costtoyou? Yes No • ¿Le gustaría que su hijo(a) tuviera un examen físico en la escuela, proveido gratuitamente por el Programa de Educación Migrante? Si No

  5. (THIS FORM IS ELECTRONICALLY GENERATED FROM THE SUMMARY FORM)

More Related