Medical History Questionnaire

Transcription

1 Medical History Questionnaire OFFICE USE Patient ID: FORM DATE: / / NAME: DATE OF BIRTH: / / Allergens No known allergens Iodine Plastic Antibiotics Latex Sedatives Aspirin Local anesthetics Sleeping pills Barbiturates Metals Sulfa drugs Codeine Penicillin : Current Medications Medicine Dosage/Frequency Reason Significant Current Medical Condition Never Past Medical History Date / Note Significant Current Date / Note Medical Condition Never Past Acid reflux Bruising easily Anemia Cancer Atherosclerosis Chemotherapy Arthritis Chronic fatigue Asthma Chronic pain Autoimmune disorder COPD Bleeding easily Coronary heart disease Blood pressure - High Current pregnancy Blood pressure - Low Depression

2 Medical History Significant Current Date / Note Significant Current Date / Note Medical Condition Never Past Medical Condition Never Past Diabetes Mood disorder Difficulty sleeping Multiple sclerosis Dizziness Muscular dystrophy Emphysema Nasal allergies Epilepsy Neuralgia Fibromyalgia Osteoarthritis Glaucoma Osteoporosis Gout Parkinson's disease Heart attack Prior orthodontic treatment Heart murmur Psychiatric care Heart pacemaker Radiation treatment Heart valve replacement Rheumatic fever Hemophilia Rheumatoid arthritis Hepatitis Sinus problems Hypertension Sleep apnea Hypoglycemia Stroke Immune system disorder Ischemic heart disease (reduced blood supply) Tendency for ear infections Thyroid disorder Kidney problems Tuberculosis Liver disease Tumors Meniere's disease Urinary disorders Mitral valve prolapse Medical Condition Current Past Date / Note Medical Condition Current Past Date / Note

3 Family History Has any member of your family (parent, sibling, or grandparent) had: Cancer Diabetes Stroke Heart disease High blood pressure Sleep disorder Obesity Thyroid disorder Patient's Occupation Father snores Mother snores Father has sleep apnea Mother has sleep apnea Social History Employer Tobacco Use: Cigarettes Never smoked Current smoker # of packs per day # of years Quit When did you quit? tobacco: Pipe Cigar Snuff Chew Alcohol Use: Do you drink alcohol? Yes No If yes, # of drinks per week: Caffeine Intake: None Coffee/Tea/Soda # of cups per day: Additional: Regular exercise Patient Signature I authorize the release of a full report of examination findings, diagnosis, treatment program etc., to any referring or treating dentist or physician. I additionally authorize the release of any medical information to insurance companies or for legal documentation to process claims. I understand that I am responsible for all charges for treatment to me regardless of insurance coverage. I certify that the medical history information is complete and accurate.

4 Review of Systems OFFICE USE Patient ID: FORM DATE: / / NAME: DATE OF BIRTH: / / General Denied Appetite changes Denied Sensitivity to heat or cold Denied Marked weight change Denied Tires easily Denied Night sweating Denied Unusual weakness Denied Recent trauma or infection Denied Denied Head, Eyes, Ears, Nose and Throat Denied Dizziness Denied Sore throat or hoarseness Denied Headaches Denied Swallowing difficulties Denied Nose bleeding Denied Trauma Denied Ringing in ears Denied Ulcers or lumps in mouth Denied Sinus infections Denied Sore gums or tongue Denied Denied Lungs Denied Persistent cough Denied Wheezing Denied Shortness of breath Denied Swelling of ankles Denied Denied Heart Denied High blood pressure Denied Denied

5 Neurologic Denied Dizziness Denied Headaches Denied Muscle weakness or paralysis Denied Denied Reproductive Denied Impotence Denied Lack of sex drive Denied Denied Denied Denied Patient Signature I authorize the release of a full report of examination findings, diagnosis, treatment program etc., to any referring or treating dentist or physician. I additionally authorize the release of any medical information to insurance companies or for legal documentation to process claims. I understand that I am responsible for all charges for treatment to me regardless of insurance coverage. I certify that the medical history information is complete and accurate.

6 Version: SLPQV2 Sleep History/Exam/Workup Questionnaire OFFICE USE Patient ID: NAME: CURRENT DATE: / / DATE OF BIRTH: / / MALE FEMALE Referring Physician: Contact ID: Number Frequency Intensity Number Frequency Intensity #1 = the most severe symptom #1 = the most severe symptom CPAP intolerance Gasping causing waking up Difficulty concentrating Excessive daytime sleepiness Fatigue Forgetfulness Insomnia Nighttime choking spells Snoring which affects the sleep of others Witnessed cessation of breathing Frequent snoring : Write In: Epworth Sleep Questionnaire How likely are you to doze off or fall asleep in the following situations? No Slight Moderate High Sitting and reading Watching TV Sitting inactive in public place (e.g. a theater or a meeting) As a passenger in a car for an hour without a break Lying down to rest in the afternoon when circumstances permit Sitting and talking to someone

7 Epworth Sleep Questionnaire How likely are you to doze off or fall asleep in the following situations? No Slight Moderate High Sitting quietly after a lunch without alcohol In a car, while stopped for a few minutes in traffic SLEEP STUDIES If you have had a Sleep Study, please check one of the following: Home Sleep Study Sleep Study / / Yes No Polysomnographic evaluation at a sleep disorder center Sleep Center Name: FOR OFFICE USE ONLY The evaluation confirmed a diagnosis of The evaluation showed: during REM Supine Side an RDI of an AHI of a nadir SpO 2 of _ T90 _ ODI _ (Oxygen Desaturation Index) Slow Wave Sleep Decreased None REM Sleep Decreased None Additional Questions Are you a current CPAP (Continuous Positive Air Pressure) user? If Yes, what are the current CPAP settings:

8 CPAP Intolerance (Continuous Positive Airway Pressure device) If you have attempted treatment with a CPAP device, but could not tolerate it please fill in this section: Refuses CPAP Mask leaks Inability to get the mask to fit properly Discomfort from headgear Disturbed or interrupted sleep include: Dieting Weight loss Surgery (Uvuloplasty) Surgery (Uvulectomy) Pillar procedure Smoking cessation CPAP Noise disturbing sleep and/or bed partner's sleep CPAP restricted movements during sleep CPAP does not seem to be effective Pressure on the upper lip causing tooth related problems Latex allergy CPAP Intolerance Claustrophobic associations An unconscious need to remove the CPAP Does not resolve symptoms Noisy Cumbersome (Continuous Positive Airway Pressure device) Therapy Attempts BiPAP Uvulectomy (but continues to have symptoms) Uvuloplasty (but continues to have symptoms) Positional therapy (side sleeping) Nasal strips

9 Patient Signature I authorize the release of a full report of examination findings, diagnosis, treatment program etc., to any referring or treating dentist or physician. I additionally authorize the release of any medical information to insurance companies or for legal documentation to process claims. I understand that I am responsible for all charges for treatment to me regardless of insurance coverage. I certify that the medical history information is complete and accurate.