Health History Form

Email Address

Today's Date

As required by law, our office adheres to written policies and procedures to protect the privacy of information about you that we create, receive, or maintain. Your answers are for our records only and will be kept confidential subject to applicable laws. Please note that you will be asked some questions about your responses to this questionnaire and there may be additional questions concerning your health. This information is vital to allow us to provide appropriate care for you. This office does not use this information to discriminate.

Patient Information

First Name

Last Name

Middle Initial

Social Security Number

Home Phone

Cell Phone

Work Phone

Preferred Method of Contact

Phone

Text

Dental Insurance

Member ID

Mailing Address

City

State

Zip

Height

Weight

Date of Birth

Sex

Occupation

Emergency Contact

How did you hear about us?

If you are completing this form for another person, what is your relationship to that person?

Your Name

Relationship

Home Phone

Cell Phone

Dental Information

Do your gums bleed when you brush or floss?

Yes

Are your teeth sensitive to cold, hot, sweets or pressure?

Yes

Is your mouth dry?

Yes

Have you had any periodontal (gum) treatments?

Yes

Have you ever had orthodontic (braces) treatment?

Yes

Have you ever had any problems associated with previous dental treatment?

Yes

Is your home water supply fluoridated?

Yes

Do you drink bottled or filtered water?

Yes

If yes, how often?

Daily

Weekly

Occasionally

Are you currently experiencing dental pain or discomfort?

Yes

Do you have earaches or neck pains?

Yes

Do you have any clicking, popping, or discomfort in the jaw?

Yes

Do you brux or grind your teeth?

Yes

Do you have sores or ulcers in your mouth?

Yes

Do you wear dentures or partials?

Yes

Do you participate in active recreational activities?

Yes

Have you ever had a serious injury to your head or mouth?

Yes

Date of your last dental exam

What was done at that time?

Date of last dental x-rays

Reason for visit

Dow do you feel about your smile?

Medical Information

Are you currently under the care of a physician?

Yes

Physician Name

Phone Number

Address / City / State / Zip

Are you in good health?

Yes

Has there been any change in your general health within the past year?

Yes

If yes, what condition is being treated?

Date of last physical exam

Do you have a history of chemical dependency?

Yes

Are you in recovery?

Yes

If yes, how long have you been in recovery?

Do you use controlled substances (drugs)?

Yes

Do you use tobacco (smoking, snuff, chew, bidis)?

Yes

If so, how interested are you in stopping?

Very

Somewhat

Not Interested

Do you drink alcoholic beverages?

Yes

If yes, how much alcohol did you drink in the last 24 hours?

Have you had a serious illness, operation or been hospitalized in the past 5 years?

Yes

If yes, what was the illness or problem?

Do you take any blood thinners?

Yes

Do you take aspirin on a regular basis?

Yes

Are you taking or scheduled to begin taking either of the medications, alendronate (Fosamax) or risedronate (Actonel) for osteoporosis or Paget's disease?

Yes

Are you taking or have you recently taken any prescription or over the counter medicine(s)?

Yes

If yes, please list all medications, including vitamins, natural or herbal preparations and/or diet supplements

Women Only Are you:

Pregnant?

Yes

Number of weeks

Taking birth control pills or hormonal replacements?

Yes

Nursing?

Yes

Have you ever had an orthopedic total joint (hip, knee, elbow, finger) replacement?

Yes

If yes, date

If yes, have you had any complications?

Allergies Please mark "Yes" if you are allergic to (or have had a reaction to) the following.

Local anesthetics

Yes

Aspirin

Yes

Penicillin or other antibiotics

Yes

Barbiturates, sedatives, or sleeping pills

Yes

Sulfa drugs

Yes

Codeine or other narcotics

Yes

Metals

Yes

Latex (rubber)

Yes

Iodine

Yes

Hay fever / seasonal

Yes

Animals

Yes

Food / Other

Yes

If yes, please specify

Please mark "Yes" if you have (or have had) any of the following diseases or problems.

Heart murmur

Yes

Mitral valve prolapse

Yes

Artificial heart valves

Yes

Rheumatic fever

Yes

Cardiovascular disease

Yes

Angina

Yes

Arteriosclerosis

Yes

Congestive heart failure

Yes

Coronary artery disease

Yes

Damaged heart valves

Yes

Heart attack

Yes

Low blood pressure

Yes

High blood pressure

Yes

Congenital heart defects

Yes

Pacemaker

Yes

Rheumatic heart disease

Yes

Abnormal bleeding

Yes

Anemia

Yes

Blood transfusion

Yes

If yes, date

Hemophilia

Yes

AIDS or HIV infection

Yes

Arthritis

Yes

Autoimmune disease

Yes

Rheumatoid arthritis

Yes

Systematic lupus erythematosus

Yes

Asthma

Yes

Bronchitis

Yes

Emphysema

Yes

Sinus trouble

Yes

Tuberculosis

Yes

Cancer / Chemotherapy / Radiation treatment

Yes

Chest pain upon exertion

Yes

Chronic pain

Yes

Diabetes type I or type II

Yes

Eating disorder

Yes

Malnutrition

Yes

Gastrointestinal disease

Yes

GE Reflux / persistent heartburn

Yes

Ulcers

Yes

Thyroid problems

Yes

Stroke

Yes

Glaucoma

Yes

Hepatitis, jaundice, or liver disease

Yes

Epilepsy

Yes

Fainting spells or seizures

Yes

Neurological disorders

Yes

If yes, please specify

Gag Reflex Sensitivity

Yes

Sleep disorder

Yes

Mental health disorders

Yes

If yes, please specify

Recurrent infections

Yes

If yes, type of infection

Kidney problems

Yes

Night sweats

Yes

Osteoporosis

Yes

Persistent swollen glands in neck

Yes

Severe headaches / migraines

Yes

Severe / rapid weight loss

Yes

STDs / STIs

Yes

Excessive urination

Yes

ADD

Yes

ADHD

Yes

Sensory Processing Disorder

Yes

Oral Sensory Sensitivity

Yes

Has a physician or previous dentist recommended that you take antibiotics prior to your dental treatment?

Yes

Do you have any disease, condition, or problem not listed above that you think we should know about?

Yes

If yes, please explain

Pharmacy Information

Pharmacy Name

Pharmacy Phone

Pharmacy Address

Signature

NOTE: Both Doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment.

I certify that I have read and understand the above and that the information given on this form is accurate. I understand the importance of a truthful health history and that my doctor and their staff will rely on this information for treating me. I acknowledge that my questions, if any, about inquiries set forth above have been answered to my satisfaction. I will not hold my doctor, or any other member of their 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.

Name of Patient/Legal Guardian

Signature of Patient/Legal Guardian

Date

All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

Submit

Thank You!

We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.

Continue

Download Printable Version

Adult Airway Questionnaire

Patient Name

Date

Please fill out this form as accurately and honestly as possible. Dr. Park understands the importance of breathing and the form and function of the upper airway that affect your total health and wellness. It is documented that the mildest form of Sleep Disorder Breathing, and or SNORING can impair neurobehavioral development. Based on the wellness model, our team will evaluate your body as a whole, treat the underlying causes, restore your body's optimal breathing, sleep habits, improve your overall health and elevate your quality of life.

Choose the most appropriate number for each situation:

0 - no chance of dozing
1 - slight chance of dozing
2 - moderate chance of dozing or sleeping
3 - high chance of dozing or sleeping

Sitting and reading

Watching TV

Sitting inactive in a public place

As a passenger in a motor vehicle for an hour or more

Lying down to rest in the afternoon when circumstances permit

Sitting and talking to someone

Sitting quietly after lunch without alcohol

In a car, while stopped for a few minutes in traffic

Total score (This is your Epworth score)

Do you breathe through your mouth?

Yes

Do you frequently get a dry throat or non-productive cough?

Yes

Do you have any nasal allergies?

Yes

Do you snore or have you been told that you snore while sleeping?

Yes

Do you stop or pause your breathing while sleeping?

Yes

Do you wake up fatigued?

Yes

Do you have morning tension or migraine headaches?

Yes

Do you easily get tired or fall asleep during the day?

Yes

Do you clench or grind your teeth during the night?

Yes

Do you clench or grind your teeth during the day?

Yes

Do you have any facial pain?

Yes

Do you usually drink alcohol or take sleep aids before going to bed?

Yes

Do you suffer from hypertension?

Yes

Have you been diagnosed with Chronic Fatigue Syndrome, Irritable Bowel Syndrome, Fibromyalgia, or Temporomandibular Syndrome?

Yes

Submit

Thank You!

We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.

Continue

Download Printable Version

Total Wellness Screening

At Park Dental Wellness, we are devoted to helping you establish your teeth and bite in optimum health, for a lifetime. We are equally committed to your whole health.

Do you have a family history of heart disease or strokes?

Yes

Do you have a family history of Type II diabetes?

Yes

Periodontal Pathogens (harmful oral bacteria):
Studies show that harmful bacteria in the mouth are a primary cause of tooth decay, bleeding gums, periodontal disease, tooth loss, and body-wide inflammation.

Have either of your parents or siblings lost their teeth or been diagnosed with periodontal disease?

Yes

Do your gums bleed easily?

Yes

Nutrition:
Studies show that whole fruits and veggies strengthen bone, gums, and teeth.

Approximately how many servings (cups) do you eat each day?

0-2

3-4

Studies show that refined foods containing sugar, flour, and white rice weaken bone, gums, and teeth. This includes sodas/diet sodas, energy drinks, juices, breads, fried foods, and processed snacks (chips, candy).

Approximately how many servings (cups) do you ingest each day?

0-2

3-4

Physical Activity:
Studies show that physical activity is critical to total wellness and that physical inactivity is “the biggest public health issue of the 21st century”

How physically active are you?

Very - I purposefully exercise several times every week.

Somewhat - I try to exercise when I can.

Not Very - I wish I were!

Toxins Exposure
Studies show that toxins, such as tobacco and mercury overexposure (fish), are significant risk facts for body-wide inflammation.

Do you smoke or chew tobacco?

Yes

Do you eat largemouth fish (bass, tuna, grouper, etc) more than once/week?

Yes

Submit

Thank You!

We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.

Continue

Download Printable Version

Patient Acknowledgement & Consent Form

Effective April 14, 2003, the new federal law known as the Health Insurance Portability and Accounting Act of 1996 (HIPAA) requires that this office comply with certain rules regarding the privacy of your information that we have collected and will collect in the future.

To comply with one of HIPAA’s requirements we have copies of our Notice of Privacy Practices in the office for your review. This Notice of Privacy Practices contains the information that HIPAA requires us to disclose regarding our privacy practices.

Existing Michigan law requires us to first obtain your written consent prior to disclosing any of your information except for your disclosures in connections with: a defense to a claim challenging our professional competence; a review entity’s functions; a claim for payment of fees; a third-party payer’s examination of our records; a court order as part of a criminal investigation; an identification of a dead body; a licensure investigation; or a child abuse/neglect investigation.

From time to time it may be necessary for us to make disclosures of your information in connection with our treatment. For example, we may make a referral to or consult with another dentist or other health care professional, provide a specimen to a laboratory for testing or otherwise make disclosures of your information in connection with providing or coordinating your treatment.

Patient Acknowledgement

I acknowledge that I have today received and/or had access to a copy of the Notice of Privacy Practices. I consent to your disclosure of my information, which you deem necessary in connection with my treatment. I understand that such disclosures may not be of the type listed above.

Patient/Parent Signature

Patient Name

I am also signing for my minor children (please list names)

I ALSO GIVE CONSENT FOR MY TREATMENT TO BE DISCUSSED WITH THE FOLLOWING INDIVIDUALS: (spouse, parent, adult child, caregiver, etc.)

Please print individual names you give permission to

Date

Submit

Thank You!

We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.

Continue

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Patient Authorization Form

I hereby certify that I have read and understood the previous information and that it is accurate and true to the best of my knowledge. I acknowledge that providing incorrect/inaccurate information has the potential of being hazardous to my health. If I ever have a change in my health, I will inform the office at my next dental appointment without fail.

I authorize the diagnosis of my dental health by means of radiographs, study models, photographs, or other diagnostic aids deemed appropriate.

I also authorize Park Dental Center, Linda M Park, to use my likeness in a photograph and/or x-rays in all publications including but not limited to printed and digital publications and advertisements. I acknowledge that I will receive no compensation for the use of my likeness.

I authorize the dentist to release any information including the diagnosis and records of treatment or examination for myself and my dependent(s) to third-party insurance carriers, payors, and/or healthcare practitioners. I authorize my insurance carrier to submit payment directly to the dentist or dental practice to be applied directly to any outstanding balance on my account.

I understand that I am financially responsible for any outstanding balance for services provided that are not fully covered by insurance, and I may be billed for this remaining balance. I consent and agree to be financially responsible for payment of all services rendered on my behalf or on the behalf of my dependents (if any) and/ or anyone covered on my insurance.

I have been informed and agree that I will be charged a $40.00 fee for appointments cancelled with less than 24 hours' notice.

Signature of Patient, Parent, or Guardian

Patient Name

Date

Submit

Thank You!

We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.

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