Welcome to the Dental Sleep Medicine Practice of: Alex J. Johnson, D.M.D., M.S Tampa Road Palm Harbor, FL

Transcription

1 Welcome to the Dental Sleep Medicine Practice of: Alex J. Johnson, D.M.D., M.S Tampa Road Palm Harbor, FL It is our goal to provide the best possible care for our patients. We take pride in being prepared for our patients prior to their office visit. In order to be prepared, we ask that you carefully complete the forms provided to you. Please complete all pages and FAX or mail to us at least 7-10 days PRIOR TO YOUR APPOINTMENT. If the forms are not received in the timeframe needed prior to your appointment, your appointment will need to be scheduled for a later time. Thank you and we look forward to meeting you. Please complete the 14 pages and return to our office. FAX#: address: nicole@dralexjohnson.com Privacy and Security communications are not considered to be as secure as returning the forms by conventional mail or FAX.

2 Welcome to the Dental Sleep Medicine Practice of: Alex J. Johnson, D.M.D., M.S Tampa Road Palm Harbor, FL As required by law, our office adheres to the written policies and procedures to protect the privacy of information about you that we create, receive or maintain. Your answers are for our records only and will be kept confidential subject to applicable laws. Please note that you will be asked some questions about your responses to this questionnaire and there may be additional questions concerning your health. This information is vital to allow us to provide appropriate care for you. This office does not use this information to discriminate. Patient: Form Date: Date of Birth: Age: Gender: q Male q Female Referring physician: Are you completing this form for another person? q Yes q No Your Name Relationship Patient Information Address: State: Zip SS#: Cell Phone: Work Phone: Home Phone: Occupation: Employer: Primary Care Physician Dentist Height/Weight: Marital Status: Sleep Apnea Physician: Emergency Contact Name: Emergency Contact Phone #: Insurance Information: Policy Holder Name: Policy Holder DOB: Policy Holder SS#: Insurance Company Group #: Ins. Phone: Thank you for choosing our office for your dental sleep medicine consultation. We respect your need to be treated promptly, and for this reason we are proud of the fact that we receive our patients at their appointed time. We are able to provide this high level of service when our patients arrive on time for their appointments. Therefore, we ask that everyone arrive on time for all scheduled appointments. Please remember that if you must reschedule your appointment, kindly give us twenty-four hours of notice. Both doctor and patient are encouraged to discuss any and all relevant health issues prior to treatment. I certify that I have read and understand the above and that the information given on this form is accurate, to the best of my knowledge, and it is my responsibility to inform the office of any changes in my health status. I understand the importance of a truthful health history and that my doctor and his/her staff will rely on this information For Staff Use Only HH Reviewed by: HH Reviewed Date: Significant Findings: Health Alerts: Dr. Initial 1

3 Sleep Consultation Patient: Form Date: Date of Birth: Age: Gender: q Male q Female Chief Complaints What are the Chief Complaints for which you are seeking treatment? Please number your complaints with #1 being the most severe, #2 the next most severe, etc. CPAP intolerance Difficulty falling asleep Fatigue Frequent heavy snoring Frequent heavy snoring which affects the sleep of others Gasping when waking up Nighttime choking spells Significant daytime drowsiness Sleepiness while driving Witnessed apneic events Inability to stay asleep Others: Please list below: Epworth Sleepiness Scale How likely are you to doze off or fall asleep in the situations described below, in contrast to feeling just tired? Use the following scale to choose the most appropriate number for each situation: 0 = would never doze or sleep. 1 = slight chance of dozing or sleeping 2 = moderate chance of dozing or sleeping 3 = high chance of dozing or sleeping Situation Sitting and reading Watching TV Chance of dozing Sitting inactive in a public place As a passenger in a car for one hour without a break Lying down to rest in the afternoon Sitting and talking to someone Sitting quietly after lunch (without alcohol) In a car, stopped for a few minutes in traffic Apnea Options PA All Rights Reserved 2

4 CPAP/BiPAP q Yes q No Are you a current CPAP (Continuous Positive Air Pressure) user? q Yes q No Have you ever used a CPAP other than during a sleep study? q Yes q No Are you CPAP intolerant? If you have attempted treatment with a CPAP device, but could not tolerate it please check all that apply in this section: Mask leaks Inability to get the mask to fit properly Discomfort from headgear Disturbed or interrupted sleep Noise disturbing sleep and/or bed partner s sleep CPAP restricted movements during sleep Claustrophobic associations An unconscious need to remove the CPAP Does not resolve symptoms Noisy Cumbersome CPAP does not seem to be effective Pressure on the upper lip causing tooth related problems Latex allergy Other Therapy Attempts If you have attempted other therapies, please check all that apply in this section: Dieting Weight loss Surgery (Uvuloplasty) Surgery (Uvulectomy) Pillar procedure Smoking cessation CPAP BiPap Uvulectomy (but continues to have symptoms) Uvuloplasty (but continues to have symptoms) History of Treatment Practioner s Name Specialty Treatment Approximate Date Apnea Options PA All Rights Reserved 3

5 Sleep History Previous Diagnosis q Yes q No Have you been previously diagnosed with Obstructive Sleep Apnea? If Yes, how long ago was it? q Years ago q Months ago q Days ago Sleep How long does it take to fall asleep? minutes Normally goes to bed at: AM PM Hours of sleep per night; hours Sleep aid: q Yes q No If yes, name the medication(s) Nasal Spray being used? q Yes q No If yes, name the medication(s) how often? Nasal Strips being used? q Yes q No If yes, how often? While sleeping, which of the following apply to you: q Yes q No Bruxism (Teeth Grinding) q Yes q No Dry mouth q Yes q No Excessive movements q Yes q No Gasping q Yes q No Hypnogogic hallucinations q Yes q No Restless legs q Yes q No Waking up and having difficulty returning to sleep q Yes q No Dreaming Getting up per night (# of times) Frequency of nocturnal urination (# of times) You normally sleep on your: side back stomach Other: Witnessed apneas are worse: q During supine sleep q Following drinking alcohol before sleeping Wake q Yes q No Sleepiness while driving q Yes q No Risks discussed regarding driving while sleepy The patient: q Yes q No Awakens unrefreshed q Yes q No Has morning headaches q Yes q No Naps: occasionally daily Snoring is reported as: q never q seldom q daily q often q light q moderate q loud q Yes q No Worse during supine sleep q Yes q No Worse following alcohol late at night 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. Authorization is hereby granted for the dental sleep medicine consultation and any necessary dental sleep services that I, the patient may have during diagnosis and treatment with my informed consent. Patient Signature: Date: Legal guardian (if applicable) I certify that the medical history information is complete and accurate. Patient Signature: Date: Apnea Options PA All Rights Reserved 4

6 Medical History Questionnaire Patient: Form Date: Date of Birth: Age: Gender: q Male q Female Yes No 1 q q Are you in good health? 2 q q Has there been any change in your general health within the past year? 3 q q Have you had a serious illness, operation or been hospitalized within the past 5 years? 4 q q Are you currently under the care of a physician for a serious illness? If yes, what was the illness or problem? 5 q q Do you require antibiotic premedication for dental procedures? 6 q q Female patients: Are you pregnant? 7 q q Do you have any physical or emotional limitations? Please list: 8 q q Do you have speech problems? Any previous therapy? If so, when: 9 q q Have you had a polysomnogram (sleep study)? When was your most recent? 10 q q Do you snore? 11 q q Have you ever been awakened by a gagging or choking reflex? 12 q q Do you breathe through the mouth rather than the nose? Sometimes Usually (circle) Dental 13 q q Have you had orthodontic (braces, splint, orthodontic appliance) treatment? If yes, when: 14 q q Have you been seen recently by your dentist? If yes, when: 15 q q Have you ever had a serious injury to your face, teeth, mouth, head or jaw joints? If yes, when: 16 q q Do your gums bleed when you brush or floss? 17 q q Do you have sores or ulcers in your mouth? 18 q q Do you wear dentures or partials? 19 q q Are you missing any permanent teeth? 20 q q Are your teeth sensitive to cold, hot, sweets or pressure? 21 q q Is your mouth dry? 22 q q Have you had any problems associated with previous dental treatment? 23 q q Are you currently experiencing dental pain or discomfort? 24 q q Have you had periodontal (gum) treatment? TMD 25 q q Have you been diagnosed previously with jaw joint (TMJ) problems? If yes, when: 26 q q Do you have jaw pain? 27 q q Do you have any clicking or popping in the jaw? 28 q q Do you have earaches or neck pain? 29 q q Have you been told you grind your teeth? 30 q q Have you been treated previously with a Dental Sleep Oral Appliance? If yes, when: Apnea Options PA All Rights Reserved 5

7 Allergens q No known allergens q Iodine q Plastic q Antibiotics q Latex q Sedatives q Aspirin q Local anesthetics q Sleeping pills q Barbiturates q Metals q Sulfa drugs q Codeine q Penicillin q q q q Current Medications Medicine Dosage/Frequency Reason Significant Medical Condition Never Current Past Date/Note Significant Medical Condition Never Current Past Date/Note q Acid reflux q q q q Bruising easily q q q q Anemia q q q q Cancer q q q q Angina q q q q Cardiovascular disease q q q q Arthritis q q q q Chemotherapy q q q q Asthma q q q q Chest pain upon exertion q q q q Autoimmune disorder q q q q Chronic fatigue q q q q Bleeding easily q q q q Chronic pain q q q q Blood pressure - High q q q q Congestive heart failure q q q q Blood pressure - Low q q q q COPD q q q q Blood transfusion q q q q Current pregnancy q q q q Bone disorders q q q q Depression q q q q Bronchitis q q q q Diabetes q q q q Difficulty sleeping q q q Apnea Options PA All Rights Reserved 6

8 Significant Medical Condition Never Current Past Date/Note Significant Medical Condition Never Current Past Date/Note q Dizziness q q q q Eating disorder q q q q Emphysema q q q q Epilepsy q q q q Fainting, seizures or dizziness q q q q Fibromyalgia q q q q Gastrointestinal disease q q q q Glaucoma q q q q Gout q q q q Heart attack q q q q Heart disorder q q q q Heart murmur q q q q Heart pacemaker q q q q Heart valve replacement q q q q Hemophilia q q q q Hepatitis q q q q Hypertension q q q q Hypoglycemia q q q q Headaches- Morning q q q q Headaches- Severe q q q q Immune system disorder q q q q Kidney problems q q q q Liver disease q q q q Lupus q q q q Malnutrition q q q q Meniere s disease q q q q Mitral valve prolapse q q q q Multiple sclerosis q q q q Muscular dystrophy q q q q Nasal allergies q q q q Neuralgia q q q q Neurological disorders q q q q Osteoarthritis q q q q Osteoporosis q q q q Parkinson s disease q q q q Persistent swollen glands q q q q Prior orthodontic treatment q q q q Psychiatric care q q q q Radiation treatment q q q q Rapid weight loss/gain q q q q Rheumatic fever q q q q Rheumatic Heart Disease q q q q Rheumatoid arthritis q q q q Sinus problems q q q q Sleep apnea q q q q Stroke q q q q Tendency for ear infections q q q q Thyroid disorder q q q q Tired / sleepy q q q q Tuberculosis q q q q Tumors q q q q Urinary disorders q q q q Ulcers q q q Confidential Medical History q Recreational drugs q q q q HIV/AIDS q q q Other Apnea Options PA All Rights Reserved 7

9 Surgical Operations q None q Heart q Tonsillectomy q Appendectomy q Hernia repair q UPPP q Adenoidectomy q Lung q Uvulectomy q Back q Nasal q q Ear q Periodontal q q Gallbladder q Thyroid q Family History q Cancer q Thyroid disorder q q Diabetes q Father snores q q High blood pressure q Mother snores q q Obesity q Father has sleep apnea q q Stroke q Mother has sleep apnea q q Sleep disorder q q Patient s Occupation: Tobacco Use: q Never smoked q Current smoker # years: # packs/day q Quit When? Other tobacco: q Pipe q Cigar q Snuff q Chew Alcohol Use: q None q Yes Caffeine Intake: Social History # drinks/week q None q Coffee/Tea/Soda # cups/day: Regular exercise q None q Yes type: 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. Patient Signature: Date: I certify that the medical history information is complete and accurate. Patient Signature: Date: Apnea Options PA All Rights Reserved 8

10 Drs. Alex and Johnny Johnson 3840 Tampa Road, Palm Harbor, FL , CONSENT FOR RELEASE OF MEDICAL RECORDS AND USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION I,, hereby authorize Drs. Alex and Johnny Johnson (hereafter collectively referred to as Practice ) to use and disclose the entire medical record concerning in accordance with the attached Notice of Privacy Practices (NOPP). I have reviewed the NOPP, been given an opportunity to ask questions about it, understand it and do hereby agree to its terms. A copy of this signed, dated Consent shall be as effective as the original. I release, hold harmless and agree to indemnify Practice, its employees and agents for any and all liability (including but not limited to negligence) arising out of or occurring under this Consent. I specifically authorize Practice to use and disclose verbally, by mail, fax or unencrypted , the following types of super-confidential information as stated in the NOPP (initial where appropriate): HIV records (including HIV test results) and sexually transmissible diseases Alcohol and substance abuse diagnosis and treatment records Psychotherapy records COMPLETE AS APPLICABLE: 1. Please send a copy of my records (including information from other health-care providers that it may contain) to at. I understand that my records may be subject to re-disclosure by recipient(s) and unprotected by federal or state law. 2. Please allow to pick up a copy of my records (including information from other healthcare providers that it may contain). The copies will be ready on. 3. I acknowledge I will be charged copying costs in the amount of. By Patient: Date: (Print name and sign) Patient s: Date of Birth: Social Security #: Or By Parent: Date: (Print name and sign) Or By Patient s Representative: Date: (Print name, sign, and describe authority) Apnea Options PA All Rights Reserved 9

11 Authorization to Release Medical Information Instructions for Completion by our patients Follow these instructions carefully when completing the authorization form. (print neatly) The form must be entirely completed. Failure to do so could result in a delay to process this request to release your medical record information. Please follow these steps: Enter the patient name (maiden or former name, if applicable, full address, birth date in the upper left corner of the form. Check the specific items you approve our office to share. In the next section enter the name, address and telephone number of the doctor to whom the information will be released. To ensure a comprehensive healthcare approach, we strongly encourage you to fill in the information on all critical care physicians you see on a regular basis. Check reason you want the information to be released. Read #7; your right to revoke your authorization on the release of your medical information from this office. Read #8; note an authorization ending date. Read #9; initial that you understand not all of your information may be protected under law. Read #10; initial that you understand that authorizing the release of your medical information is voluntary. Under AUTHORIZATION SIGNATURES the patient, parent or legal/personal representative must date and sign the form. (Patient signs on first line; parent or patient representative signs on third line down and lists their relationship to the patient). Please note: If the individual signing the authorization form is a Guardian, Executor of the Estate or Power of Attorney for the patient, that person must submit a copy of the appropriate legal document, which proves authority to act on behalf of the patient. This must accompany the authorization form. Bring this form, competed, with you to your scheduled appointment at Apnea Options. or Mailing Instructions: The form cannot be processed unless it contains the required signatures and date. Mail the completed form and any required legal documents to the Apnea Options, where your records to be released are located at 3840 Tampa Road, Palm Harbor, Florida Per HIPAA GUIDELINES, a copy of this form must be retained by the patient.

12 Authorization to Use or Disclose Health Information Patient Name: Phone #: Address: Date of Birth: SS #: 1. I authorize the use or disclosure of the above named individual's health information as described below 2. The following individual(s) or organization(s) are authorized to make the disclosure: 3. The type of information to be used or disclosed is as follows: (check the appropriate boxes and include other information where indicated) Please retain a copy of completed form prior to mailing original to Apnea Options. _ ALL Documents Listed Below _ Face Sheet / Registration Sheet / Referral Sheet _ Health History Information _ SOAP Report Exam summary _ Medication List _ Consultation Information _ Progress Notes _ Substance Abuse Information _ Appliance Instructions _ Human Immunodeficiency Virus (HIV) Information _ Lab Results _ Radiology / x-ray films and reports _ Home Care Records _ Polysomnogram (Sleep Study) report _ Photos _ Pulse Oximetry Reports 4. I understand that if my authorization includes Behavioral Health, substance abuse or HIV information, it may include; (i) information concerning whether an individual has been the subject of an human immunodeficiency virus (HIV) - related test, has HIV, an HIV related illness, acquired immunodeficiency syndrome (AIDS), and/or including information pertaining to the individual's contact (Section ); (ii) substance abuse information in my health record may include whether or not I am receiving treatment, my prognosis, a brief description of my progress, and/or a short statement as to whether I have relapsed into substance abuse and the frequency of such relapse (Behavioral health information services -Mental Health Procedures act 1976, section ). 5. The information identified above may be used by or disclosed to the following individual or organization(s): Primary Care Physician Name: Address: Phone Sleep Medicine Physician Name: Cardiologist Name:

13 Dentist Name: Ear, Nose and Throat Physician Name: Neurologist Name: Neurosurgeon Name: Orthopedist Name: Physical Therapist Name: Psychiatrist Name: Psychologist Name: Pulmonologist Name: Rheumatologist Name: Other Name:

14 6. This information for which I'm authorizing disclosure will be used for the following purpose: _ Sharing with other health care providers as needed _ Other (please describe): 7. I understand that I have a right to revoke this authorization at any time. I understand that if I revoke this authorization, I must do so in writing and present my written revocation to the medical record department. I understand that the revocation will not apply to information that has already been released in response to this authorization. I understand that the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy. 8. Unless I specify differently, this authorization will expire twelve months from the date signed below: Date 9. I understand that once the above information is disclosed, it may be re-disclosed by the recipient and the information may not be protected by federal privacy laws or regulations. Initial 10. I understand authorizing the use or disclosure of the information identified above is voluntary. I need not sign this form to ensure healthcare treatment. Initial Signature of patient or legal representative: Date If signed by legal representative, relationship to patient Signature of witness Date A copy of this authorization form has been included with the copy of the medical record. The patient has given verbal authorization to release the above identified information. I have witnessed the verbal authorization. The patient has been informed of the nature of the authorization and freely gives his or her consent. Signature of witness Date Signature of witness Date

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