Health History Form

Parent/Legal Guardian's 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

Preferred Name

Gender

Date of Birth

Previous Visit

Dental Insurance

Member ID

Contact Information

Home Phone

Cell Phone

Work Phone

Preferred Method of Contact

Phone

Text

Mailing Address

City

State

Zip

Parent/Legal Guardian's Name(s)

Pediatrician's Name

Pediatrician's Phone Number

Health History

Does your child have any medical conditions or disabilities?

Yes

If yes, please list

Have you ever been told your child needs antibiotics before a dental visit?

Yes

Has your child ever had heart or cardiac problems?

Yes

Has your child had any surgeries or hospital visits?

Yes

If yes, please list

Does your child take any medications on a daily basis?

Yes

If yes, please list

Does your child have any food or medication allergies?

Yes

If yes, please list

Is your child allergic to latex, pine nuts, or dairy products?

Yes

If yes, please list

Does your child have asthma or reactive airway disease?

Yes

What asthma medications were used last and when?

Please select all the conditions your child currently has, or HAS HAD in the past.

Heart Murmur

Cleft Lip/Palate

Tuberculosis

Hepatitis

Seizures

Hearing/Visually Impaired

Rheumatic Fever

Diabetes

Developmental Delay/CP

Eczema

HIV/AIDS

Ports/Catheters

Anemia/Sickle Cell

Ear Problems

Autism/PDD

Liver/Kidney Disorders

ADD/ADHD

Cancer

None

Does your child have any physical or mental disabilities or speech problems?

Yes

If yes, please explain

Dental History

What is the reason for your visit?

Is this your child's first visit to the dentist?

Yes

How do you think your child will do at this visit?

Good

Apprehensive

Uncooperative

Has your child ever had a negative dental experience in the past?

Yes

Has your child had a toothache recently?

Yes

If yes, please explain

Does your child have any of the following habits?

Finger Sucking

Pacifier

Teeth Grinding

None

What type of water does your child drink?

Tap

Fridge

Bottle

Brita

Pur

Other

Has your child ever had any injuries to the jaw, head, mouth, or teeth?

Yes

If yes, please explain

Is there anything else about your child that you think we should know in order to better treat their dental needs?

Signature

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

I acknowledge that the above information is correct and grant permission to provide my child’s dental and related medical/surgical treatment as deemed necessary, utilizing proper and acceptable methods used in the specialty of pediatric dentistry to complete their treatment.

If there is a change in my child’s health, allergy or medication history, I will inform the dentist & staff immediately prior to any future appointments.

Name of Parent/Legal Guardian

Signature of Parent/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

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Pediatric 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.

Please check all that apply:

While sleeping, does your child snore more than half the time?

While sleeping, does your child always snore?

While sleeping, does your child snore loudly?

While sleeping, does your child have "heavy" or loud breathing?

While sleeping, does your child have trouble breathing, or struggle to breathe?

Has your child ever stopped breathing at night?

Does your child occasionally wet the bed, sleepwalk, or have night terrors?

Does your child tend to breathe through their mouth during the day?

Does your child have a dry mouth on waking in the morning?

Does your child wake up unrefreshed in the morning?

Does your child wake up with headaches in the morning?

Is it hard to wake up your child in the morning?

Does your child have a problem with sleepiness during the day?

Has a teacher or supervisor commented - your child appears sleepy during the day?

Did your child stop growing at a normal size since birth?

Is your child overweight?

Does your child not seem to listen when spoken to?

Does your child often have difficulty organizing tasks and activities?

Is your child easily distracted by extraneous stimuli?

Does your child often fidget with their hands or feet, or squirm in their seat?

Is your child often “on the go” or acts as if “driven by a motor”

Does your child often interrupts or intrudes on others? (butts in conversations or games)

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

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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.

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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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