Screening Questions to Ask Patients

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Margaret Morton
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1 Screening Questins t Ask Patients 1. Have yu ever had TB (Tuberculsis)? Yes N 2. Have yu been living with anyne in the past tw years that has been diagnsed with TB? Yes N 3. Have yu ever had a Persistent cugh and night sweats fr mre than tw weeks? Yes N 4. Have yu had a persistent cugh and fever fr mre than tw weeks? Yes N 5. Have yu ever had a persistent cugh and lss f appetite fr mre than tw weeks? Yes N 6. Have yu been cughing up r spitting up bld sputum (saliva)? Yes N American Assciatin f Physician Office and Labratries

2 ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES *Yu May Refuse t Sign This Acknwledgement* I,, have received a cpy f this ffice s Ntice f Privacy Practices. Please Print Signature Fr Office Use Only We attempted t btain written acknwledgement f receipt f ur Ntice f Privacy Practices, but acknwledgement culd nt be btained because: Individual refused t sign Cmmunicatin barriers prhibited btaining the acknwledgement An emergency situatin prevented us frm btaining acknwledgement Other (Please Specify) 2002 American Dental Assciatin All Rights Reserved

3 PEDIATRIC DENTISTRY CONSENT FOR DENTAL PROCEDURE AND ACKNOWLEDGEMENT OF RECEIPT OF INFORMATION 1. State Law requires us t btain yur cnsent t yur child s cntemplated dental treatment r ral surgery. Please read this frm carefully and ask abut anything that yu d nt understand. We will be pleased t explain it. I hereby authrize and direct Dr. Ppe Ozimba assisted by ther dental and/r dental auxiliaries f her chice, t perfrm upn my child (r legal wrd fr whm I am empwered t cnsent) the fllwing dental treatment r ral surgery prcedure(s). 2. In general terms the dental treatment r prcedures will include: A. Radigraph (x rays) f the teeth and jaws. B. Cleaning f the teeth and the applicatin f tpical fluride. C. Applicatin f plastic sealants t the grves f the teeth. D. Use f lcal anesthesia t numb the teeth and tissues. E. Treatment f diseased r injured teeth with dental restratins (fillings). F. Remval (extractin) f ne r mre teeth. G. Treatment f diseased r injured ral tissues (hard and/r sft). H. Treatment f malpsed (crked) teeth and/r ral develpment r grwth abnrmalities. I. Use f sedative drugs t cntrl apprehensin and/r disruptive behavir. J. Use f General Anesthesia t accmplish the necessary treatment. The nature and purpse f the treatment and prcedures have been explained tme in general terms by Dr. Ppe Ozimba and/r assistant. Alternates purpse f the treatment and prcedures have been explained t me, as have their advantages and disadvantages, the risks, cnsequences and prbable effectiveness f each, as well as the prgnsis if n treatment is prvided. I am advised that thugh gd results are expected, the pssibility and nature f cmplicatins cannt be accurately anticipated and that, therefre there can be n guarantee as expressed r implied either as t the rest f the treatment r as t cure. I further authrize the dctr t perfrm ther dental services that in her judgment are advisable fr my child r legal ward, with the exceptin f (if nne s State):. 3. I als authrize Dr. Ppe Ozimba t use phtgraphs, radigraphs, and ther diagnstic material and treatment recrds fr the purpse f teaching, research, and scientific publicatins. 4. Althugh their ccurrence is nt frequent, sme risks and cmplicatins are knwn t be assciated with dental r ral surgery prcedures. The mst cmmn cmplicatin assciated with pediatric dental treatment includes nausea fllwing the administratin f tpical fluride and children biting and injuring the tngue r lip fllwing administratin f lcal anesthesia. Less cmmn cmplicatins includes the risks f numbness, infectin, swelling prlnged bleeding, disclratin, vmiting, allergic reactins, swallwing r aspiratin f a crwn frm, and extracted tth r gauze packing; injury t the tngue and/r lips, damage t and pssible lss f existing teeth and/r restratins (fillings), injury t nerves near the treatment site and fracture f a tth rt which may require additinal surgery fr its remval. Fr children with heart disease, the risk f subacute bacterial endcarditic (heart infarctin) fllwing dental treatment exists, therefre antibitics will be prescribed befre and fllwing treatment, t minimize risk. I further understand and accept that cmplicatins may require additinal medical, dental, r surgical treatment and may require hspitalizatin. I hereby state that I have read and understand this cnsent frm, that I have been given an pprtunity t ask questins I might have, and that all questins abut the prcedure r prcedures have been answered in a satisfactry manner; and I understand further that I have the right t be prvided with answers t questins which may arise during the curse f my child s treatment. I further understand that I am free t withdraw my cnsent t treatment at any time, and that this cnsent will remain in effect until such time that I chse t terminate it. Patient s : Signature f Parent/Guardian: Time Relatinship t Patient: I certify that I explained the abve prcedures t the parent r legal guardian befre requesting their signature Signature f Dentist

4 Behavir Management Infrmed Cnsent T the parent/guardian f: Child s Birth date As a cncerned dentist, I wuld like t discuss with yu the methds f managing yur child s behavir during treatment. While children are usually cperative and brave, smetimes they can be frightened by the equipment and the unknwn experience. This is especially true fr children yunger that three years, but it als hld true t sme lder children. In rder t treat yu child safely, we may have t use these aids: Muth Rester, t help hld the child s muth pen t prvide the dentist with better access and prevents the child frm biting dwn n a wrking drill. If a child falls asleep during the prcedure, the Muth Rester will enable the dentist t cntinue t wrk withut waking the child. Hlding Assistant, helps secure the child, prtecting and psitining him n the dental chair. In additin, the assistant may cmfrt, massage, and sthe the child. This persn may be yu, parent/guardian. Papse bards, Pedi Wraps and/r Pillw Case, these are prtective restraining stabilizers fr limiting yur child s mvement t prevent injury t the child and the prviders. Prtective stabilizatin enables the dentist t prvide the necessary dental treatment. This child is wrapped in these stabilizers and placed in a reclined dental chair. Nte: Befre giving us permissin t use these aids, please feel free t ask questins r express any cncerns. Please rest assure that yu child will receive ptimal treatment with us. These behaviral management aids are nly used when necessary. Thank Yu. Yes, I give permissin fr my child t be treated at Dr. Jeannette M. Ppe Ozimba s Pediatric Dental Office. If necessary, yu may use the Muth Rester, Hlding Assistant and Prtective Stabilizatin. N, I d nt give permissin fr my child t be treated at Dr. Jeannette M. Ppe Ozimba s Pediatric Dental Office and will take him/her t anther facility fr treatment. If I fail t d s, I understand my child s dental cavities may get wrse. Parent/Guardian Dctr Interpreter/Witness

5 CONSENT FOR TREATMENT I am the (parent r guardian) f (name f child) wh is a minr child and I authrize examinatin and treatment as necessary by r under the supervisin f Dr. Ppe Ozimba. This includes expsure f radigraphs as necessary, use f lcal anesthetic, reasnable restraints as needed, and use f apprpriate medicaments and material fr such treatment. I give yu ffice cnsent t discuss treatment cncerning the abve mentined minr child t the fllwing individual(s): I understand that the abve persn(s) can nt sign any cnsent frms pertaining t treatment fr the abve mentined minr child. I READ AND UNDERSTAND THE ABOVE INFORMATION AND THE INFORMATION GIVEN TO ME VERBALLY. BY MY SIGNATURE I CONSENT TO THE TREATMENT DESCRIBED IN THIS CONSENT FORM. Parent Signature Witness

Street Address: City: State: Zip: Home Ph: Cell Ph: SSN#: Name: Relationship to Patient: Address: City: State: Zip: Home Ph: Cell Ph:

PATIENT INFORMATION Name: Birthdate: Street Address: City: State: Zip: Hme Ph: Cell Ph: Email: SSN#: Sex (circle) M F Emplyer Name & Phne #: PARENT/GUARDIAN INFORMATION (IF UNDER THE AGE OF 18) Name: Relatinship