PATIENT HEALTH HISTORY

Patient Health History
* required field

Patient Health History

Your Responses are for our records only and are considered strictly confidential.

Patient Information













Medical History

Is your child presently under a physician's care, or has been during the past 5 years (including hospitalizations and ER visits)? *

Please select all those that apply to your child



























Surgical History

Did your child experience any of the following




Medications

Please list all medications that your child is presently taking (antibiotics, pain medication, heart medicine, vitamins)

Allergies

Please list allergic reactions your child has had to the following







Dental History

Is this your child's first time *



Were any x-rays taken during previous dental visits?
Does your child have any injuries to the teeth, face or mouth? *

Is the child's water fluoridated?
Is the child taking fluoride supplements?
Does the child brush daily? *
Does the child floss daily? *
Does your child have or do any of the following?







Please check the words that best describe your child














GENERAL CONSENT TO TREATMENT / HEALTH INFORMATION CERTIFICATION

Because your child is a minor, it is necessary that we receive signed permission from a parent or guardian before any and/or all necessary dental services can be started and completed by Gerstenmaier Pediatric Dentistry. Authorization is hereby granted as such. Furthermore, by signing below, I am verifying the provided information is correct and I will be financially responsible for any treatment provided for this child.



Acknowledgement of Receipt of Notice of Privacy Practices and Your Rights to Access Your Patient Files Health Insurance Portability and Accountability Act (HIPPA)

I acknowledge that I have been offered my copy of the above Notice of Privacy Practices and Your Rights to Access Your Patient Files to read. I understand that I may request a copy to keep for my files. My signature also gives my written consent to Gerstenmaier Pediatric Dentistry to use and disclose my health care information as set forth in this notice, except as I give specific written notice of restriction.




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