Pediatric Review of Systems Form

 

Confidentiality:  As a patient of Dr. Alex Kaminsky, you have certain privacy expectations as well as rights and our clinic is fully compliant with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) privacy and security rules for health care providers.  We understand the importance of privacy and are committed to maintaining the confidentiality of your medical information.  We are required by law to maintain the privacy of protected health information, to provide individuals with notice of our legal duties and privacy practices with respect to protected health information, and to notify affected individuals following a breach of unsecured protected health information.

 

Please reference all areas of pain by the letter(s) in the diagram

George's Cerebrovascular Craniocervical Function Test

Have you ever been diagnosed or told you have any of the following?

George's Cerebrovascular Craniocervical Function Test Continued

Have you ever had any of the following, even short, temporary attacks, in the last year?

Thank you, submit form and we will print out for you to sign at our office

Parent Signature:
_____________________________________________________________________Date____________________________