Orthodontic Questionnaire. Please tell us why you have presented for evaluation and possible treatment. Dental History

Transcription

1 Orthodontic Consultation file:///c:/programdata/nierman/dentalwriternet/reports/out.html Version: ORTHOQ Orthodontic Questionnaire OFFICE USE Patient ID: NAME: -' Crowding ' Overbite CURRENT DATE: / / -' MALE DATE OF BIRTH: / / Please tell us why you have presented for evaluation and possible treatment -' Don't like my smile --' My dentist found the problem J Thumb sucking - I Appearance '-.) Tongue habit -` Better function '-t Mouth breathing ---' Airway assessment ` Teasing at school Other HABITS FEMALE Referring Physician: Contact ID: Dental History If the patient has ever sucked their thumb or 'D Patient plays a musical (mouth) instrument finger, until what age? D.--` -1 Patient has consulted an orthodontist or another dentist Does the patient have any speech problems? regarding the orthodontic or TMJ problem -' - Does the patient breathe through the mouth? _1 during the day _i during the night 2 during the day and night -' Other Has one or more parent had previous ortho treatment? Chief concern TMD Health Questionnaire Patient Concerns and Onset Date of onset 1 of 4 2/24/2016 2:53 PM

2 Orthodontic Consultation file:///c:/programdata/nierman/dentalwriternet/reports/out.html ' Headaches JMigraine headaches YOUR PAIN SYMPTOMS Frequent neck aches or sore neck muscles - Chronic shoulder or back pain J Trouble sleeping soundly - Jaws tired on waking D Teeth sore on waking TMD Health Questionnaire Pain Symptoms -' Headaches in right or left temple areas Headaches in front or back of head J Teeth clenching during day TJTeeth clenching at night J Teeth grind when asleep When are your pain symptoms are the worst? Does anything make you feel better? How often do you take medication for relieft of pain? ' 11 Wisdom teeth have been extracted Trauma Have you ever had a severe blow to the head 1 Have you ever been involved in any serious accidenst, such as or jaw? car accident ' ' Any whiplash neck injuries? Other Symptoms and History 2 of 4 2/24/2016 2:53 PM

3 Orthodontic Consultation file:///c/programdata/nierman/dentalwriternet/reports/out.html TMD Health Questionnaire JAW JIONT SYMPTOMS Do you suffer from any loss of hearing? 'J 'D Does your jaw feel tired after a big meal? Do you have itchiness or stuffiness in either ear? U Are there any foods you avoid eating? U Do you hear ringing, hissing or buzzing noises in either ear? J J Do you ever get dizzy? Do you wear glasses or contacts J U Do you ever feel faint? U Are there times when your eyesight blurs? Do you ever feel nauseated? - Do you get pain in, around or behind either eye? Is there a family history of jaw joint (TMJ) problems or headaches? BREATHING -' Do you feel or hear a "clicking", "popping" or "cracking" noise from either jaw joint? U Do you have allergies? 'J Has your jaw ever locked when you were unable to open or close? Do you have sinus problems? 3 J Do you have difficulty opening wide or yawning? Do you snore at night? Have you ever had pain in either jaw joint? Is your nose stuffed when you don't have a cold? Does your jaw aqche when you open wide? Have you been diagnosed with Sleep Apnea? EAR AND EYE SYMPTOMS Cj Have you had a sleep study done at a Sleep Clinic (hospital)? Do you have pain in either ear? 2/24/2016 2:53 PM

4 Orthodontic Consultation file:///c:/programdata/nierman/dentalwriternet/reports/out.html Patient Signature Because of HIPAA Federal regulations protecting your privacy, we wish to inform you that we will release no information about you without your consent. By agreeing to this consent, you permit the release of any information to or from your dental practitioner as require including a full report of examination findings, diagnosis and treatment program to any referring or treating dentist or physician. You nderstand that you are financially responsible for all charges whether or not paid by insurance. Your dental practitioner may use your health care information and may disclose such information to your Insurance Company(ies) and their agents for the purpose of obtaining ayment for service and determining insurance benefits or the benefits payable for related services. I certify that the medical history information is complete and accurate. anent Si nature: DRAW YOUR PAIN PATTERNS FOLLOWING THIS KEY DRAW YOUR PAIN PATTERNS FOLLOWING THIS KEY: MLD PAIN MODE DATE PAIN Am\ SEVERE PAIN B Burning O Dull N Numbing P Pressure S Sharp T Tingling R Radiating Mild, numbing pain D Moderate, dull pain R Severe, radiating pain Pressure RIGHT 42> db* I LEFT LEFT RIGHT RIGHT EFT Enter any text to appear below the image: 2/24/2016 2:53 PM

5 BLAINE P. CUSACK, B.S., D.D.S. Clinical Director/ General Dentist Medical/ Dental Records Release American Academy of Pain Management American Board of Orofacial Pain Academy of Dental Sleep Medicine Credentialed by the Certification Board of the Academy of Dental Sleep Medicine I, the undersigned hereby authorize Dr. Cusack to release to, any and all of my medical/ dental information and records including office notes, medical charts, x-rays, MRI films, and letters received while under his care. Please forward any and all medical/dental records, MRI films, x-rays, etc. your facility has on file for me to. Dr. Blaine P. Cusack 475 W. 55th St. Suite 207 La Grange, IL Phone: (708) Fax: (708) Patient Name (print) Date Address SS# City, State, Zip Patient's Date of Birth x Patient Signature Witness Comprehensive Dental Care for Head, Neck & Facial Pain, TM Disorders and Sleep Appliance Therapy / Biological Dentistry 475 W. 55th Street Suite 207 LaGrange, IL Phone: Fax:

6 BLAINE P. CUSACK, B.S., D.D.S. Clinical Director / General Dentist PATIENT CONSENT FORM American Academy of Pain Management American Board of Orofacial Pain Academy of Dental Sleep Medicine Credentialed by the Certification Board of the Academy of Dental Sleep Medicine I understand that, under the Health Insurance Portability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to: Conduct, plan and direct my treatment and follow-up among the multiple health care providers who may be involved in that treatment directly and indirectly. Obtain payment from third-party payers. Conduct normal healthcare operations such as quality assessments and physician certification. I have been informed by you of your notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I have been given the right to review such tice of Privacy Practices from time to time and that I may contact this organization at any time at the address below to obtain a current copy of the tice of Privacy Practices. I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or health care operations. I also understand you are not required to agree to my requested restrictions, but if you do agree then you are bound to abide by such restrictions. I understand that I may revoke this consent in writing at any time, except to the extent that you have taken action relying on this consent. Patient Name Patient Signature Relationship to patient Date Comprehensive Dental Care for Head, Neck & Facial Pain, TM Disorders and Sleep Appliance Therapy / Biological Dentistry 475 W. 55th Street Suite 207 LaGrange, IL Phone: Fax:

7 American Academy of Pain Management American Board of Orofacial Pain Academy of Dental Sleep Medicine Credentialed by the Certification Board of the Academy of Dental Sleep Medicine BLAINE P. CUSACK, B.S., D.D.S. Clinical Director / General Dentist FINANCIAL TERMS AND CONDITIONS As a condition of treatment by Dr. Cusack and his office, I understand that financial arrangements must be in advance. The practice depends upon reimbursement from the patients for the costs incurred in that care and financial responsibility on the part of each patient must be determined before treatment. All emergency dental- medical services, performed without prior financial arrangements must be made in cash at the time services are performed. I understand that dental/ medical services furnished to me are charged directly to me and that I am personally responsible for payment of all dental/ medical services. If I carry insurance forms to assist in making collections from insurance companies. However, this office cannot and will not render services on the assumption that charges will be paid by an insurance company. A service charge of 1 1/2% per month (18% per annum) will be charged on the unpaid principle balance on all accounts not paid within 60 days of the treatment date. In consideration of the professional service rendered to me, or at my request, by Dr. Cusack and/ or his staff, I agree to pay the value of said services to the Doctor, or his assignee, at the time the service are rendered, or within (5) days of billing if credit shall be extended. I further agree for payment there for. Additionally, I agree that a waiver of any further terms or condition. I further agree that in the unlikely event that his office must institute collection proceedings with request to amounts owed by me for professional services rendered, this office shall be entitled to recover all costs incurred including and not limited to reasonable collection and or attorney fees. I grant my permission to you, or your assigned to telephone me at work to discuss any matter related to this form. I have read the above conditions, understood them and agree to their consent. Signed Date Relationship Witness Comprehensive Dental Care for Head, Neck & Facial Pain, TM Disorders and Sleep Appliance Therapy Biological Dentistry 475 W. 55th Street Suite 207 LaGrange, IL Fax: