Medical History Update

Enter names of children to update health history for using this form.

Patient 1

Patient’s First Name:

Last Name:

DOB:

Patient 2

Patient’s First Name:

Last Name:

DOB:

Patient 3

Patient’s First Name:

Last Name:

DOB:

Patient 4

Patient’s First Name:

Last Name:

DOB:

Patients’ Primary Address:

City:

State:

Zip:

Who does the patient live with?

Both Parents

Mother

Father

Other:

Parent’s/Guardian’s First Name:

Last Name

Home Number

Cell/Mobile Number

Email

Who is accompanying the child today or is expected to on the date of their appointment?

First Name:

Last Name:

Is your child a ward of the state?

Yes

If yes, case worker's contact number:

ALLERGIES

Does the patient have an ALLERGY to LATEX?

Yes No

Does the patient have an allergy to TREENUT

Yes No

Does the patient have any OTHER ALLERGIES?(For example: Animals, Foods, Medications, Nickel, etc)

Yes No

If YES, what allergies?

MEDICATIONS

Is the patient currently taking ANY medications/vitamins?

Yes No

If YES, what medications/vitamins?

Why is the patient taking this medication (i.e., what condition is it for)?

DENTAL CONCERNS

Do you (or the patient) have any DENTAL CONCERNS?

Yes No

If YES, what concerns do you have?

CONSENT FOR TODAY

X-Rays (if needed): Essential for diagnosing tooth decay and other abnormalities

Yes No

Fluoride Application: To help fight tooth decay and strengthen developing teeth

Yes No

ALLERGIES

Does the patient have an ALLERGY to LATEX?

Yes No

Does the patient have an allergy to TREENUT

Yes No

Does the patient have any OTHER ALLERGIES?(For example: Animals, Foods, Medications, Nickel, etc)

Yes No

If YES, what allergies?

MEDICATIONS

Is the patient currently taking ANY medications/vitamins?

Yes No

If YES, what medications/vitamins?

Why is the patient taking this medication (i.e., what condition is it for)?

DENTAL CONCERNS

Do you (or the patient) have any DENTAL CONCERNS?

Yes No

If YES, what concerns do you have?

CONSENT FOR TODAY

X-Rays (if needed): Essential for diagnosing tooth decay and other abnormalities

Yes No

Fluoride Application: To help fight tooth decay and strengthen developing teeth

Yes No

ALLERGIES

Does the patient have an ALLERGY to LATEX?

Yes No

Does the patient have an allergy to TREENUT

Yes No

Does the patient have any OTHER ALLERGIES?(For example: Animals, Foods, Medications, Nickel, etc)

Yes No

If YES, what allergies?

MEDICATIONS

Is the patient currently taking ANY medications/vitamins?

Yes No

If YES, what medications/vitamins?

Why is the patient taking this medication (i.e., what condition is it for)?

DENTAL CONCERNS

Do you (or the patient) have any DENTAL CONCERNS?

Yes No

If YES, what concerns do you have?

CONSENT FOR TODAY

X-Rays (if needed): Essential for diagnosing tooth decay and other abnormalities

Yes No

Fluoride Application: To help fight tooth decay and strengthen developing teeth

Yes No

ALLERGIES

Does the patient have an ALLERGY to LATEX?

Yes No

Does the patient have an allergy to TREENUT

Yes No

Does the patient have any OTHER ALLERGIES?(For example: Animals, Foods, Medications, Nickel, etc)

Yes No

If YES, what allergies?

MEDICATIONS

Is the patient currently taking ANY medications/vitamins?

Yes No

If YES, what medications/vitamins?

Why is the patient taking this medication (i.e., what condition is it for)?

DENTAL CONCERNS

Do you (or the patient) have any DENTAL CONCERNS?

Yes No

If YES, what concerns do you have?

CONSENT FOR TODAY

X-Rays (if needed): Essential for diagnosing tooth decay and other abnormalities

Yes No

Fluoride Application: To help fight tooth decay and strengthen developing teeth

Yes No

ACKNOWLEDGEMENT OF RECEIPT OF HIPAA NOTICE OF PRIVACY PRACTICES

Below is a list of ways our office may contact you. Please check all that apply. Checking a box will give permission to leave as thorough of a message as needed from our dental office.

PHONE NUMBER

Patient Authorization for Use and Disclosure of Protected Health Information
I authorize Fishers Pediatric Dentistry to release any information including diagnosis and the records regarding any treatment or examination rendered to my child during the period of such dental care to third party payers and/or other health practitioners. In the event of my absence, the following individuals may bring my child/children to and from their appointments along with have access to medical and financial information.

1. First Name:

Last Name:

Relationship to patient:

Contact Number:

2. First Name:

Last Name:

Relationship to patient:

Contact Number:

Click to view NOTICE OF PRIVACY PRACTICES

I, , have been offered a copy of this office’s Notice of Privacy Practices.

I certify that the information I have given is correct to the best of my knowledge. It will be held in confidence and it is my responsibility to inform this office of changes in the patient’s medical status. I authorize the dental staff to perform all necessary dental treatment the patient may need. I authorize the release of all information necessary to secure benefits otherwise payable to me. I assign directly Fishers Pediatric Dentistry all insurance payments otherwise payable to me. I understand that I am responsible for the full balance of the account regardless of my dental benefits. I understand that the office operates on a 15-day billing cycle and account balances are due and payable when the statement is issued, and is past due if not paid by the date printed on the statement. If necessary, unpaid accounts may be sent to a collection agency. I acknowledge that my questions, if any, about inquiries set forth above have been answered to my satisfaction. I will not hold the dentist or any member of the staff responsible for any action they take or do not take because of errors or omissions that I may have made in the completion of this form. I affirm that my signature represents my agreement to all the above mentioned terms.

Signature (* required)

Date:

MEDICAL HISTORY UPDATE & HIPAA NOTICE OF PRIVACY PRACTICES

All questions contained in this questionnaire are strictly confidential and will become part of the patient’s record.
A Medical History Update must be provided at every dental visit.

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MEDICAL HISTORY UPDATE & HIPAA NOTICE OF PRIVACY PRACTICES ACTUALIZACIÓN DEL HISTORIAL MÉDICO & EL AVISO DE PRÁCTICAS DE PRIVACIDAD

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Patient: 2 - Click to expand/collapse section

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Patient: 4 - Click to expand/collapse section

MEDICAL HISTORY UPDATE & HIPAA NOTICE OF PRIVACY PRACTICES