Name Home Phone Work Phone Address Cell Phone Occupation Birthdate Employer Spouse Referred by Physician Phone Date of Last Physical Exam
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1 Patient History Form William P. Glaros, DDS Name Home Phone _ Work Phone Address Cell Phone _ Occupation Birthdate Employer Spouse Referred by Physician _ Phone Date of Last Physical Exam Past / Present Past / Present YES NO YES NO Heart/Chest pain Abnormal EKG Heart Attack Heart Surgery Mitral Valve Prolapse Heart Murmur Endocarditis Rheumatic Fever High/Low Blood Pressure Stroke Seizures Shaky Hands/Feet Twitching of Muscles Bell's Palsy Multiple Sclerosis Chronic Anemia Sickle Cell Emphysema Bronchitis Asthma Sinus Problem Hypoglycemia Insomnia Eye conditions Caffeine Alcohol Yes No Lyme Disease Kidney Disorders GI Disorders Diabetes Arthritis High/Low Thyroid S.T.D. HIV Lupus T.B. Cancer Hepatitis Shingles Emotional Disturbances Vegetarian Use Sugar Use Sugar Substitutes Use Tobacco Use Recreational Drugs Use Fen Phen Use Hormones Bisphosphonates Could you be pregnant? What is your primary health concern? I use Nutritional Supplements I take medications - list them I have allergies to medications, food, latex or environmental - list them I have allergies to metals- list them I have had a problem wearing false fingernails I have headaches: Frequency How severe? Relieved by _ I have discomfort chewing in teeth in the jaw I clench or grind my teeth Are you pleased with the appearance of your teeth? Are you concerned about dental materials in your mouth? Frequent sore throats Lymph glands swell frequently Short term memory loss Rapid fatigue Low body temperature Bouts of depression Trouble making decisions Frequent urination Ringing in my ears I am on special diet Metallic taste in my mouth Numbness of fingers or toes Infections take long time to heal I have worked around Mercury Rapid heartbeat-unrelated to exercise Experience tingling in my body List all surgeries: From past surgical experiences, did you find your healing to be: Eventful Uneventful Date: Patient Signature _ What is your present dental interest? Is there anything you would change about your teeth if you could? Doctor Signature
2 William P. Glaros Kuykendahl Road, #150 Spring, TX Office: Fax: Thank you for letting us help you in your quest for optimum health! To help us help you, please describe your reasons for seeking dentistry in our office. Be as specific as you can. We appreciate your taking the time to outline your needs and concerns. Name Date Signature _
3 The Epworth Sleepiness Scale How likely are you to doze off or fall asleep in the following situations? Check one in each row: No chance Slight chance Moderate chance High chance Sitting and reading Watching TV Sitting inactive in a public place (e.g. a theater or a meeting) As a passenger in a car for an hour without break Lying down to rest in the afternoon when circumstances permit Sitting and talking to someone Sitting quietly after a lunch without alcohol In a car, while stopped for a few minutes in traffic Patient Signature: Date
4 TO OUR PATIENTS CONCERNED WITH MERCURY/SILVER FILLINGS Controversy abounds on the subject of mercury amalgam silver fillings. The American Dental Association (ADA) and its supporting bodies are convinced that there is not enough scientific evidence to justify removing such fillings or question their continued placement. Dr. Glaros position on this matter is not the same as the ADA s. Reportedly, 50% of dentists in the USA do not use mercury fillings: They are mercury-free. However, only a small percentage of mercury-free practices are also mercury-safe, consistently following stringent protocols for protecting patients, dentist and staff, and the environment. Our office has been mercury-free and ever more mercury-safe since Some people report significant improvement in their health after offending restorations are removed. Others are unaware of any changes in their health. Improvement in medical conditions or general health as a result of removing any or all existing dental restorations is not implied, predicted or promised by Dr. Glaros or this office. (initial) Removal of any dental restoration for any reason carries the potential risk of damaging tooth structure and causing irreversible problems, including sensitivity and possible loss of the existing tooth. Such consequences are unfortunate and unpredictable. I have been informed by Dr. Glaros of the potential consequences of dental restoration removal. (initial) We test and strive to use the most compatible materials for each patient on an individual basis. The absolute safety and compatibility of new dental materials cannot be guaranteed. (initial) In response to individual requests, Dr. Glaros may consider removing amalgam fillings or other restorations. Our procedure is to first do a thorough oral examination followed by a slightly varying protocol for individual evaluation and treatment. This procedure in no way allows a diagnosis of toxicity to mercury or any other material. That is a medical matter to be taken up by the patient and his or her physician and/or other health care provider. We may make referrals outside this office to help our clients make self-determining decisions about their own health care, detox protocols, and supplementation. Patient consultation with their health care provider is strongly recommended. In signing this letter, I acknowledge that I have read it in full, that no promises about improved health have been made and that I am exercising a personal right of self-determination regarding my own health care. that I acknowledge and consent to submission of my electronic signature. Patient Signature Date Witness Signature Date
5 With Whom Are You Working to Assist in Your Detox? When it comes to mercury hygiene and its protocols for safest removal, we feel secure that what we offer is the highest level of care. Stopping a source of contamination of your body seems basic. It is equally critical to take your best steps to get the mercury and heavy metal toxins OUT of your body. That is where the question comes, With whom are you working to assist with your nutrition and heavy metal detox? Some of our patients have been the masters of their own nutrition/detox for years and do not feel the need for outside support. Most of the people we treat are working closely with a holistically oriented MD, chiropractor, ND, nutritionist, and/or someone who they have confidence in to assist them. We have seen both of these choices work quite well. If no one is addressing your detox/nutrition, you are increasing the likelihood that heavy metals are staying stored in your organs or are recirculating in your body and redistributing. We want the toxins out, be it through your bowels, your bladder, or your sweat all good. We want the toxins out, and we want your supplementation to replace the toxins that have been sitting in critical parts of your body taking up space but are unable to be productive. With whom are you working is not meant to be a barrier to you seeking the care that you are trying to get. It is an invitation to assist you in seeking your optimal health. If you need assistance, we can help by offering names of practitioners with whom our other patients are and have been working. If you are the one in charge of this area, we only need to hear that from you. You and your health are the reason we are here. I have read and understand the importance of working with someone for my detox. I am working with I am in the process of finding the best person to assist me for my detox. Signature Date
6 New Patient Agreement to Office Policies William P. Glaros, DDS Dr. Glaros appreciates your trust and interest in scheduling a new patient exam. We take pleasure in reserving a special amount of time to listen to your specific needs knowing you are wanting the highest quality of care and time to discuss your unique situation. In order to serve you, our schedule must be carefully arranged for you. Your Initials Your appointment time is being held for you. If you need to change the date, we ask that you give us seven (7) days notice. Your health form is to be filled out and submitted seven (7) days before your new patient exam. This will insure that all necessary paper work has been completed and allows for prompt attention to your appointment time. A panoramic xray and individual radiographs are required at the initial exam for obtaining baseline information and diagnosis. The panoramic xray gives a full view of the upper and lower jaw and the individual radiographs allow a closer view of each tooth. You will be given a homeopathic following any x-rays taken. If you have had any of these x-rays taken within the last "6 months" and would like Dr. Glaros to use use them, you will need to contact your previous dental office and have them ed 7 days before your exam. You are responsible for this transaction or new x-rays will be taken the day of your exam with Dr. Glaros. I have read and agree to all of the policies listed above. Signature Date_
SLEEP SCREENING QUESTIONNAIRE
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Patient Information 433 W. University Dr. Rochester, MI 48307 www.rochesteradvanceddentistry.com +1 248 656-2020 SLEEP SCREENING QUESTIONNAIRE Name: DOB: Age: Address: Employer: SS# Home Phone: Work Phone:
Last Name: First Name: Address: City: State: Zip: Home #: Work #: Mobile #: Gender: SS#: DOB: Marital Status: Employer:
Thank you for the opportunity to evaluate your dental condition. In order to provide the best service for you, please complete the following information. About You Last Name: First Name: Address: City:
Welcome to the office of
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PATIENT REGISTRATION Patient's Name (Last, First, MI): Date of Birth: Age: Sex: M / F Social Security Number: Address: Apt. # City: State: Zip: Home Number: Mobile Number: Work Number: Employment Status:
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Welcome to the Minnesota Craniofacial Center for TMJ & Sleep Treatment!
2550 UNIVERSITY AVE WEST SUITE 143N ST. PAUL, MN 55114 (651) 642-1013 FAX (651) 642-0947 www.mncranio.com Welcome to the Minnesota Craniofacial Center for TMJ & Sleep Treatment! Snoring used to be considered
Baptist Health Floyd 1850 State Street New Albany, IN Sleep Disorders Center Lung & Sleep Specialists. Date of Birth: Age:
Page 1 of 7 GENERAL INFORMATION Name: Date of Birth: Age: Social Security #: Sex: Height: Weight: Address: City: State: Zip: Home Phone: Cell Phone: Work Phone: Employer s Name: Marital Status: Married
PATIENT HEALTH HISTORY
PATIENT HEALTH HISTORY Patient Name Today s Date Birthdate DENTAL HISTORY Reason for Today s Visit Are you having dental pain now? Former Dentist Date of last dental visit Last x-rays Check (!) if you
PEDIATRIC HISTORY FORM
Lehigh Valley Health Network Pediatric Sleep Center PEDIATRIC HISTORY FORM Please answer the following questions frankly and accurately by filling in the blank or checking/circling the appropriate answer.
Jason A Boch DMD LLC Jason A. Boch, DMD DMSc Diplomate of the American Board of Periodontology
Jason A Boch DMD LLC Jason A. Boch, DMD DMSc Diplomate of the American Board of Periodontology Patient Information Patient Name: of Birth: Gender (M/F): Name of Parent (if patient is a minor): Home Address:
Creating and maintaining your oral health is our primary goal. Thank you for giving us the opportunity to pursue this goal with you.
Welcome to our wonderful family of patients. Thank you for selecting us as your personal dental care team. We will strive to make your relationship with us a pleasant and rewarding one. A firm foundation
Welcome to Medina Family Chiropractic and Acupuncture!
Welcome to Medina Family Chiropractic and Acupuncture! Please fill out this form and return it to the front desk. Let us know if you have any questions! Personal information Date: First name: Middle name:
Welcome to South 40 Dental! Tell Us About Yourself
Welcome to South 40 Dental! Tell Us About Yourself Name: Last First MI Title Preferred Name: Male Female Parent/Guardian Name if Under 18 Years Old: Address: City Prov. Postal Code Date of Birth (day)
SLEEP SCREENING QUESTIONNAIRE
SLEEP SCREENING QUESTIONNAIRE This questionnaire was designed to provide important facts regarding the history of your sleep condition. To assist in determining the source of any problem, please take your
Medical Health Information (continued):
Patient s Name (please print): Date: / / Medical Health Information (continued): The following questions are for your benefit and assure that treatment will take into consideration your past and present
NAME: last first middle Mr. Mrs. Ms. Dr. city state zip Single Married Divorced Widowed Separated
WELCOME! The benefits of a happy, healthy smile are immeasurable! Our goal is to help you reach and maintain maximum oral health. Please fill out these forms completely. The better we communicate, the
Medical and Dental Health History Form Getting to Know You As Our Patient
Medical and Dental Health History Form Getting to Know You As Our Patient Account number: Date: Patient name (first and last): Name of previous dentist/location: Date of last dental examination: Date of
MEDICAL HISTORY. PATIENT NAME Birth Date
TIME 10:17 AM Lund Dental Associates DATE 8/26/2013 MEDICAL HISTORY PATIENT NAME Birth Date Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire
Bariatric Surgery Patient History Questionnaire
Bariatric Surgery Patient History Questionnaire Your appointment will be delayed if this form is incomplete please print legibly Personal Information Name Date SSN# (for insurance purposes) - - Date of
Emergency Contact Information Name: Phone: Address: Employer Information Employer Name: Address/Street: City: Zip: Phone: Fax:
SUNSET SLEEP LABS PATIENT INFORMATION FORM Patient Information Name: Sex: M F Date of Birth: Address/Street: City: Zip: Phone: Alt Phone: Parent/Guardian: Phone: Social Security Number: Drivers License: