NAME: last first middle Mr. Mrs. Ms. Dr. city state zip Single Married Divorced Widowed Separated

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1 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 better we can care for you. TODAY S DATE: NAME: last first middle Mr. Mrs. Ms. Dr. BIRTHDATE: / / AGE: SSN: HOME ADDRESS: city state zip Single Married Divorced Widowed Separated Home #: Cell #: Work #: Ext # _ Dental Insurance Medical Insurance Person financially responsible: IF DIFFERENT FROM PATIENT (relationship to patient) Where & when are best times to reach you? Who may we THANK for referring you? Previous Dentist: Last dental visit: Primary Care Physician Phone : Referring Physician Phone : Sleep Physician Phone : Other Physicians you are under the care of: DENTAL HISTORY / INFORMATION Why have you come to the dentist today? Do you have or have you experienced any of the following: (please check) Serious / difficult problem associated with any dental work Pain or discomfort in your jaw joints (TMJ) Face sore or feel tight in the morning Jaw sometimes difficult to open or close, clicking or popping Clenching or grinding your teeth Teeth sensitive to cold, heat, pressure or sweets Unpleasant taste in your mouth or persistent bad breath Teeth loose or shifting Bleeding gums How would you evaluate your dental health: Excellent Good Fair Poor Do you have any skin allergies? (This would include reactions to wearing jewelry) Yes No

2 SOCIAL HISTORY Employer: Occupation: Children Yes/No If yes, how many children? What are their ages? Are you currently under unusual stress? Y/N Recent change in lifestyle? Y/N Do you chew tobacco? Y/N Do you exercise regularly? Y/N Do you smoke Y/N If so, # Alcohol consumption-none/social Drinker/Occasional/Daily MEDICAL HISTORY per day/week Your current physical health is: Excellent Good Fair Poor Are you currently under the care of a physician? No Yes If yes, please explain: Are you taking any prescriptions / over-the-counter drugs? Medicine Dose/Times per day For For Women only: Are you taking birth control pill? No Yes Are you pregnant? No Yes Are you nursing? No Yes Have you ever had any of the following disease or medical problem? (PLEASE CHECK) Heart attack / stroke Please list any serious medical condition(s) that you have ever had: Mitral Valve Prolapse Heart murmur Rheumatic fever Congenital heart defect Heart surgery / pacemaker Shingles Cancer / chemotherapy Kidney problems Artificial bones / joints Sinus problems Are you allergic to any of the following drugs? (Please check) High / Low blood pressure (circle) Fever blisters Severe / frequent headaches Penicillin Tetracycline Psychiatric problems Aspirin Dental anesthetics Epilepsy / Seizures / Fainting spells Erythromycin Codeine Diabetes Latex Other Tuberculosis (TB) Drug / Alcohol abuse Venereal disease Please list any other drugs that you are allergic to: Hemophilia / Abnormal bleeding HIV+ / AIDS Anemia / Radiation treatment Asthma / hay fever Difficulty breathing Hepatitis Blood transfusion E M E R G E N C Y C O N TACT : Emphysema Glaucoma Ulcers / colitis Thyroid disease Nervous disorder Name: Phone #: THANK YOU! For filling out these forms completely. It will enable us to help you more effectively. If you have any questions at any time, please ask us. We are happy to help. I understand that I am responsible for the payment of all charges for services rendered, regardless of insurance, and that any amount remaining unpaid more than 60 days after the services were rendered will accrue interest at the rate of 18% per annum. Should the account be turned over to an attorney, I agree to pay 33.3% attorney s fees and all court costs. I understand that if I cancel an appointment without giving at least 48 hours prior notice, I may be charged $150 per each hour scheduled. (NOTE: Leaving a message on our answering machine does not constitute proper notice to the practice.) SIGNATURE: PATIENT or Patient s Parent/or Child Guardian DATE:

3 Smile Assessment Form Please consider each statement carefully and circle YES or NO. The Doctor and members of the dental team will discuss your responses with you in confidence. Name: Date: 1 I am concerned about the appearance of my teeth or smile. YES NO 2 I am concerned about the whiteness/lack of whiteness of one or more of my teeth. YES NO 3 I am concerned about the position or angle of one or more of my teeth. YES NO 4 I am concerned about the shape of one or more of my teeth. YES NO 5 In social situations, my teeth or smile sometimes embarrasses me. YES NO 6 There are some things about my upper front teeth I would like to change. YES NO 7 There are things about my lower front teeth that I would like to change. YES NO 8 I have old fillings or previous dental treatment that is no longer satisfactory to me. YES NO 9 I am missing one or more of my teeth. YES NO 10 I am interested in learning more about: Cosmetic dentistry Sedation Dentistry Invisalign Whitening YES YES YES YES NO NO NO NO Please use the space below to indicate any other problems, concerns, or questions you may have. We will make every effort to listen attentively to your concerns so that we may present you with the best possible treatment options. Thank you.

4 HCJ H. Charles Jelinek, Jr., D.D.S The STOP-BANG Questionnaire A Tool to Screen Patients for Obstructive Sleep Apnea (OSA) 1. Snore. Have you been told you snore? Do you snore loudly (louder than talking or loud enough to be heard through closed doors)? Yes No 2. Tired. Do you often feel tired, fatigued, or sleepy during daytime? Yes No 3. Obstruction. Do you know if you have stopped breathing or has anyone observed you stop breathing while you are asleep? Yes No 4. Pressure. Do you have or are you being treated for high blood pressure? Yes No 5. Body Mass Index (BMI). IS you BMI more than 30 (use the formula to calculate your BMI)? Yes No BMI Formula: (your weight in pounds X 703) BMI = (your height in inches X your height in inches) 6. Age. Are you 50 years or older? Yes No 7. Neck. Is your neck circumference greater than 17 inches for a male or 15 inches for a female? Yes No 8. Gender. Are you a male? Yes No Scoring: Answering "yes" to three of more of the 8 questions indicates that you are High Risk for OSA. Answering yes to less than three questions indicates that you are Low Risk for OSA. If you scored in the High Risk for OSA category, a sleep study or an evaluation by a sleep specialist may be warranted Arlington Blvd., Suite 260. Fairfax, VA Phone (703) Fax (703)

5 HCJ H. Charles Jelinek, Jr., D.D.S Initial Patient Sleep Screening Form v. 1.0 Patient Name (PRINT) Section 1: Epworth Sleepiness Scale Please indicate how likely you are to doze off or fall asleep in the following situations: (0=never, 1=slight, 2=moderate, 3=high chance of dozing) CIRCLE ONE RESPONSE FOR EACH QUESTION Sitting and reading Watching television Sitting in a public place As a passenger in a car for one hour Driving a car stopped for a few minutes in traffic Sitting & talking to someone Sitting down quietly after lunch without alcohol Lying down to rest in the afternoon Total Score: Section 2: Patient Evaluation Fill in the blanks, circle one yes or no response for each question No (0) Yes (1) BMI (See Attached Chart): Is it greater than or equal to 30? 0 1 Neck Circumference Is it >17 (Men) or >15 (Women)? 0 1 Have you gained at least 15 pounds in the past 6 months? 0 1 Total Score: Section 3: Subjective Sleep Evaluation Please circle one yes or no response for each question No (0) Yes (1) Do you snore? You, or your spouse, would consider your snoring louder than a person talking 0 1 Your snoring occurs almost every night Your snoring is bothersome to your bed partner Do you feel that in some way your sleep is not refreshing or restful? Do you wake up at night or in the mornings with headaches? Do you experience fatigue during the day and have difficulty staying awake? Do you have trouble remembering things or paying attention during the day? Do you have high blood pressure? Total Score: Section 4: Prior Diagnosis Have you previously been diagnosed with sleep apnea? 0 1 If Yes: When were you diagnosed? (Approx mo/yr) Were you put on CPAP Therapy for treatment? Are you still using your CPAP every night? Total Score: No(0) Yes(1) Notes: (Please insert any notes for the doctor regarding snoring, sleep patterns or sleep apnea that you feel may be appropriate use back of page if necessary.) Patient Signature: Date: / / OFFICE USE ONLY Advanced screening criteria, if yes to any below pt should be scheduled for advanced OSA screening. ESS Score 8? Pt. Eval 2? Subjective Sleep Eval 3? Prior OSA Diagnosis 1? 8505 Arlington Blvd., Suite 260. Fairfax, VA Phone (703) Fax (703)

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8 H. CHARLES JELINEK, JR., D.D.S. ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES CONSENT FOR USE AND DISCLOSURE OF HEALTH INFORMATION SECTION A: PATIENT GIVING CONSENT Name: Address: Telephone: SECTION B: TO THE PATIENT PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY. Purpose of Consent: By signing this form, you will consent to our use and disclosure of your protected health information to carry out treatment, payment activities, and healthcare operations. Notice of Privacy Practices: You have been given a copy of our Notice of Privacy Practices to read before you decide whether to sign this Consent. Our Notice provides a description of our treatment, payment activities, and healthcare operations, of the uses and disclosures we may make of your protected health information, and of other important matters about your protected health information. Your copy of our Notice accompanies this Consent. We encourage you to read it carefully and completely before signing this Consent. We reserve the right to change our privacy practices as described in our Notice of Privacy Practices. If we change our privacy practices, we will issue a revised Notice of Privacy Practices, which will contain the changes. Those changes may apply to any of your protected health information that we maintain. You may obtain a copy of our Notice of Privacy Practices, including any revisions of our Notice, at any time by contacting: Telephone: Fax: Address: 8505 Arlington Blvd. Ste. 260 Fairfax, VA Right to Revoke: You will have the right to revoke this Consent at any time by giving us written notice of your revocation submitted to the Contact listed above. Please understand that revocation of this Consent will not affect any action we took in reliance on this Consent before we received your revocation, and that we may decline to treat you or to continue treating you if you revoke this Consent. My protected health information for treatment, payment activities and health care operations may be released to the persons I have specified below: Name: Relationship: Telephone: Health information Financial information Name: Relationship: Telephone: Health information Financial information SIGNATURE I,, have had full opportunity to read and consider the contents of this Consent form and your Notice of Privacy Practices. I understand that, by signing this Consent form, I am giving my consent to your use and disclosure of my protected health information to carry out treatment, payment activities and health care operations. Signature: Date: If this Consent is signed by a personal representative on behalf of the patient, complete the following: Personal Representative s Name: Relationship to Patient: For Office Use Only We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgement could not be obtained because: Individual refused to sign Communications barriers prohibited obtaining the acknowledgement An emergency situation prevented us from obtaining acknowledgement Other (Please specify):

9 HCJ H. Charles Jelinek, Jr., D.D.S VOLUNTARY RELEASE FOR USE OF WRITTEN OR VIDEO REVIEW H Charles Jelinek, Jr., D.D.S. may publish your testimonial as part of our effort to continue providing the best dentistry to as many patients as possible. Participating by signing this release is completely voluntary on your part. In order to do so, please read carefully and sign below: I do hereby remise, release and forever discharge H Charles Jelinek, Jr., D.D.S. or any of its assigns, parents, affiliated companies, their licensees, persons or companies exhibiting or scheduled to exhibit the material, their advertising agencies and the officers, directors, agents, and employees of the foregoing companies of and from all rights, claims, liabilities, known or unknown, whether at law or in equity, that may hereafter at any time be made or brought by me for the purpose of enforcing any claim or cause of action arising out of the use, sale, broadcast, transfer, distribution, or other dissemination of said program, testimony and/or videotape recording herein described. I acknowledge your ownership of recorded or written material and further agree that you may use my name and likeness for the purpose of promoting the H Charles Jelinek,Jr.,D.D.S. and/or photography. I warrant and represent that all material furnished by me is my own for which I have full authority for such purposes. H Charles Jelinek, Jr., D.D.S.: PRINT NAME: SIGNATURE: DATE: (If a minor, parent or guardian signature) PHONE: ( ) WITNESS: 8505 Arlington Blvd., Suite 260. Fairfax, VA Phone (703) Fax (703)