CENTRAL FLORIDA ORAL & MAXILLOFACIAL SURGERY, PA PATIENT REGISTRATION Date: PATIENT INFORMATION

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1 CENTRAL FLORIDA ORAL & MAXILLOFACIAL SURGERY, PA PATIENT REGISTRATION Date: Pre-fix: Patient s Legal First Name: PATIENT INFORMATION Legal Last Name: Nickname: Mr Mrs Ms Dr Street Address: Home Phone #: ( Work Phone #:( Sex: Male Female Cell Phone #:( Social Security Number: Marital Status: Single Married Divorced Separated Widow Primary Language: Address: Patient s School Name: Full time Part time Not a Student Patient s Employer Name: Full time Part time Retired Not Employed How did you hear about our practice? Patient s General Dentist Name: General Dentist Phone #: ( Patient s Physician Name: Physician Phone #: ( Patient s Orthodontist Name (if applicable: Orthodontist Phone #: ( Has a family member ever been a patient of our practice? Yes No Emergency Contact Name: If Yes, their name: Relation to Patient: BILLING INFORMATION Phone #: ( ONLY IF PATIENT IS A MINOR (under 18 years old Father s Last Name: First: Street Address (if different from patient: Best Contact Phone #: ( Mother s Last Name: Social Security # (Required: First: Street Address (if different from patient : Best Contact Phone #: ( Social Security # (Required: INSURANCE INFORMATION In order to process your insurance claim, we MUST have a copy of all your current insurance cards. In addition, ALL of the following MUST be provided. MEDICAL INSURANCE Medical Insurance Name (if None, write None : Claims Address: Insurance Phone #: ( Policy Type: PPO HMO Medicare Indemnity Work Comp Other Policy Type: Group/Employer Individual Medical Insurance Policy/ID #: Medical Group #: Policy Holder Last Name: First:

2 Policy Holder Street Address (if different from patient: Social Security #: Policy Holder Employer: Policy Holder s Relationship to Patient: Self Spouse Parent Step-Parent Other (please explain DENTAL INSURANCE Dental Insurance Name (if None, write None : Claims Address: Insurance Phone #: ( Policy Type: PPO HMO Indemnity Discount Plan Dental Insurance Policy/ID #: Dental Group #: Policy Holder Last Name: First: Policy Holder Street Address (if different from patient: Social Security #: Policy Holder Employer: Policy Holder s Relationship to Patient: Self Spouse Parent Step-Parent Other (please explain ACCIDENT INFORMATION Is treatment due to an accident or injury? Yes No; If Yes please provide the following information. (If No, skip to ALL PATIENTS Describe how the injury/accident occurred: If auto accident injury; Auto Insurance Policy ID#: Accident Claim #: If work related injury; Workers Comp Claim #: Date of Accident/Injury: Agent/Adjuster Name: Phone #: ( Dates you have been unable to work: thru Do you have an attorney for this case? Yes No If yes; name: Phone #: ( ALL PATIENTS By signing below, I acknowledge the above information as being correct and agree to notify CFOMS as changes may occur. I also agree to pay any deductible, co-pay, co-insurance, or other amounts not covered by insurance. The signature below serves as a signature on file authorizing CFOMS to release any medical/dental records by law for appropriate care with other providers; to process any insurance claims; and to receive payment/ insurance benefits otherwise payable to the insured. Should I not pay the portion as stipulated above, I shall be liable for payment of any late charges or collection fees that may result. I acknowledge that I am the responsible party for this account. If patient is a minor, I certify that I am a legal guardian of the patient. Signature of Responsible Party: Printed Name: Date: OFFICE USE ONLY I Certify there are no changes to information above Patient Signature Date / / Front Office Representative Initials I Certify there are no changes to information above Patient Signature Date / / Front Office Representative Initials I Certify there are no changes to information above Patient Signature Date / / Front Office Representative Initials I Certify there are no changes to information above Patient Signature Date / / Front Office Representative Initials

3 TMJ Medical History Central Florida Oral & Maxillofacial Surgery, PA PATIENT S NAME: DATE: BIRTH DATE: AGE: M F MARITAL STATUS: S M W D OCCUPATION: PLEASE CHECK EACH ITEM YES OR NO AS THEY RELATE TO YOUR HEALTH *If yes, then explain on back of this page. Review of Systems (14 Systems Health History of Patient Do you now or in the past 6 months have: Yes No Yes No Yes No Headaches Nausea / Vomiting Asthma Sinus Headaches Heartburn Stroke Chest Pain Difficulty Swallowing Heart Trouble Jaw Pain Diarrhea High Blood Pressure Toothache Constipation Diabetes Sleep Apnea Arm / Calf Pain Arthritis Snoring Heart Skipping / Racing Gout Weight Loss / Gain Mood Swings Seizures Fever Significant Stress Mental Illness Fatigue (Lack of Energy Easy Bruising Cancer Double Vision Gums Bleed Easily Bleeding Disorders Blurred Vision Prolonged / Excessive Bleeding Alcoholism Ringing in Ears Joint Pain / Stiffness Lung Disease Vertigo / Dizziness Joint Swelling Tuberculosis Frequent Sore Throat Muscle Pain Phlebitis Sinus Infections Back Pain Anemia Hearing Loss Seizures Stomach Ulcer Loss of Smell Numbness / Tingling Liver Trouble Nasal Congestion Hesitant / Slurred Speech Thyroid Trouble BM/Urinary Problems Coldness of hands / feet Fibromyalgia Hay Fever / Airborne Allergies Weakness of body part Sexual Disease Hives / Eczema Trouble Walking Depression Shortness of Breath Rash / Sores / Lesions Sleep Disorder Coughing Blood Changes in a mole Serious Injuries Persistent Cough Heat / Cold Intolerance AIDS Stomach Pain Unusual Lumps or Enlarged Glands Migraines Please list all your medications (herbal, over the counter and prescribed: Allergic to any drugs? (please list List All Surgeries: FAMILY HISTORY Yes No SOCIAL HISTORY Yes No Headaches Do you smoke? Packs per day Heart Problem Do you drink alcohol? Drinks per day: Drinks per week: High Blood Pressure Recreational Drugs? None: Presently: Past: Cancer Caffeine Use: Drinks per day: Cancer Caffeine Stimulant Use: Tabs / week I certify the above medical information is correct. Signed: Date: BCENOR041

4 Central Florida Oral & Maxillofacial Surgery Form B-Sleep Page 1 of 4 Sleep Apnea Patient Questionnaire Date: Patient Name: Age: Male Female Height: Weight: Name of Referring Doctor: Address: Phone: ( Name of Primary Care Physician: Address: Phone: ( Chief Complaint: (What are your reasons for being here: History of Present Illness: (Give a brief description of how your problem started and how it progressed When did this begin? Date(s of Sleep Studies (please bring any reports to your appointment: Do the Following Statements Apply to you? 1. Weight Gain? lbs Loss? lbs YES NO 2. High Blood Pressure YES NO 3. Diabetes YES NO 4. Swollen Uvula YES NO 5. Cardiac Arrhythmias YES NO 6. Excessive Daytime Sleepiness YES NO 7. Morning Headaches YES NO 8. Loud Snoring YES NO 9. Gasping/Choking YES NO 10. CHF (Congestive Heart Failure YES NO 11. Nasal/Chest Congestion YES NO 12. Restless Sleeper YES NO 13. Chronic Obstructive Pulmonary Disease YES NO 14. Awakening with Dry Mouth YES NO 15. Airway Restriction YES NO 16. Cannot tolerate CPAP machine? YES NO 17. Is CPAP working for you? YES NO 18. Would you like to try an oral appliance? YES NO

5 Central Florida Oral & Maxillofacial Surgery Form B-Sleep Page 2 of 4 Date: Patient Name: Have you received any of the following treatments in the past for your sleep disturbance/snoring? Circle all that apply 1. Counseling for Weight Reduction? YES NO 2. Counseling for Nicotine Reduction or Cessation? YES NO 3. Counseling for Alcohol Reduction or Cessation? YES NO 4. Counseling for Caffeine Reduction or Cessation? YES NO 5. Exercise Therapy YES NO 6. Sleep-Position Change YES NO 7. Medication? YES NO 8. Use Nasal Continuous Positive Airway Pressure (CPAP? YES NO 9. Can you tolerate your CPAP machine? YES NO 10. Is CPAP working for you? YES NO 11. Use Bilevel positive airway pressure (BiPAP? YES NO 12. Oral Appliance Therapy YES NO 13. Surgery For Sleep Apnea YES NO 14. What other treatment(s, if any have you received for this problem in the past? 15. How often does this occur? Almost every night For periods of at least one week Irregularly Other: 16. How do you describe your sleep problem? Check all that apply. Difficulty falling asleep Wake up during the night Excessive daytime sleepiness Difficulty awakening 17. Do any other members of your family have sleep problems? Yes No 18. How many hours of sleep do you usually get each night? 19. What time do you go to bed on the WEEKDAYS (Mon-Fri? 20. What time do you go to bed on the WEEKENDS (Sat-Sun? 21. What time do you usually awaken on the WEEKDAYS (Mon-Fri? 22. What time do you usually awaken on the WEEKENDS (Sat-Sun? 23. How long does it take for you to fall asleep? 24. How many times do you typically wake up at night? 25. If you wake up, on average, how long do you stay awake? 26. If you awaken during the night (after you fall asleep, which part of your sleep period is it? Soon after falling asleep Middle of the night Early Morning

6 Name: Date: EPWORTH SLEEPINESS SCALE How likely are you to doze off or fall asleep in the following situations? Even if you have not done some of these things recently, try to work out how they would have affected you. Please circle the appropriate number below: 0= would NEVER doze 1= SLIGHT chance of dozing 2= MODERATE chance of dozing 3= HIGH chance of dozing Situations Chance of Dozing Sitting and reading Watching TV Sitting inactive in a public place (e.g. Theater or 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 Sitting quietly after a lunch without alcohol In a car, while stopped for a few minutes in the traffic Total: 1. Do you snore? YES NO 2. Do you have fragmented sleep? YES NO 3. Do you feel that you get restorative sleep? YES NO

7 Central Florida Oral & Maxillofacial Surgery Form A Page 5 of 5 Date: Patient Name: Release of Medical Information It is standard practice to supply a letter to the physician or dentist who referred you to our practice, as well as other physicians or dentists that may have evaluated you for your problem or may need to become a referral for your problem in the future. (i.e. primary care physician or neurologist This letter contains a description of your problem, medical history, examination results, test results, diagnosis and treatment recommendations. YOUR REFERRING DOCTOR WILL RECEIVE THIS LETTER Please list any additional doctors below that you would like to receive this letter. (Please supply all information 1. Name: 2. Name: Address: Address: State ZIP State ZIP ( ( ( ( Phone # Fax # Phone # Fax # 3. Name: 4. Name: Address: Address: State ZIP State ZIP ( ( ( ( Phone # Fax # Phone # Fax # Signature of Patient Date:

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