ARNETT GUNSON FACIAL RECONSTRUCTION

Transcription

1 ARNETT GUNSON FACIAL RECONSTRUCTION G. William Arnett, DDS, FACD Michael J. Gunson, DDS, MD 9 E Pedregosa Street Santa Barbara, CA Telephone Fax PATIENT INFORMATION: Today s First Name MI Last Name Sex: M F Birth Age Soc. Sec. # Street Apt City State Zip Country Mobile ( Home Tel. ( Referred By Dentist Phone ( Orthodontist Phone ( Medical Doctor 1 Phone ( Medical Doctor 2 Phone ( Employer Bus. Tel. ( Emergency Contact Tel. ( Relation How do you prefer to be contacted? Home# Mobile# Mail How did you hear about our practice? PERSON RESPONSIBLE FOR YOUR ACCOUNT: Self (if self, skip this section Spouse Father Mother Other Name Soc. Sec. # Birth Age Phone ( Street Apt City State Zip Country Employer Bus. Tel. ( SPOUSE OR OTHER GUARANTOR INFORMATION: (IF DIFFERENT FROM ABOVE Name Relation Birth Soc. Sec. # Street Apt City State Zip Country Tel. ( Employer Bus. Tel. ( AUTHORIZATION I authorize my surgeon and designated staff to perform an oral and maxillofacial examination for the purposes of diagnosis and treatment planning. Furthermore, I authorize the taking of all x-rays (scans required as a necessary part of this examination. In addition, I authorize the release of any information acquired in the course of my examination and treatment to my other doctors and/or insurance carriers. Signature of patient (Patient or Guardian if Minor I hereby acknowledge a copy of this office s Notice of Privacy Practices (HIPAA Information sheet has been made available to me. Signature of patient (Patient or Guardian if Minor

2 MEDICAL HISTORY Reason for today s office visit? bite correction joint pain joint function muscle pain facial pain sleep apnea facial appearance dental appearance speech difficulty cleft palate repair other symptoms started Have your symptoms increased with time?... Y N Height Weight Are you in good health?... Y N Hospitalizations/Surgeries Reason Complications: nausea, bleeding, anesthetic, prolonged healing, allergies Have you or any family member had any unusual or serious reactions to general or local anesthetic?... Y N Is there a family history of: cancer diabetes heart disease bleeding arthritis... Y N Do you use: pipe cigar chewing tobacco cigarettes (packs per day How long? Y N Do you use any recreational drugs? List: Y N Do you drink alcoholic beverages? If so, number of drinks per day... Y N History of medication, drug, or alcohol abuse?... Y N FEMALES ONLY Is there a possibility that you are pregnant? If so, months due date Y N Are you nursing?... Y N Has your menstrual cycle been irregular in the past?... Y N Do you currently have an irregular menstrual cycle?... Y N Do you currently have a regular menstrual cycle?... Y N At what age was your first menstrual cycle? If menopausal, at what age did this start? Are you currently taking or have you ever used birth control?... Y N Current birth control type: Pill IUD Injection Name How long? Previous birth control type: Pill IUD Injection Name How long? NOTE: Antibiotics may alter the effectiveness of birth control pills. Consult your physician / gynecologist for assistance regarding other methods of birth control while on any antibiotics. MEDICATIONS Are you taking Blood thinners (Coumadin, Plavix, Aspirin, Vitamin E, garlic, fish oil, etc.?... Y N Are you taking or have ever taken bone density medications and/or bisphosphonates (Actonel, Boniva, Fosamax, Intravenous Aredia or Zometa?... Y N Are you taking or have ever taken diet pills? Name How long? Y N Please list ALL medications, herbal supplements, or homeopathic remedies you are currently taking: Medications Dosage Frequency Page 2

3 ALLERGIES OR HAD REACTION TO: Local anesthetics Penicillin s Cephalosporin s Tetracycline Other antibiotics Sulfa drugs Aspirin NSAIDS (ibuprofen, naproxen, etc. YES NO ALLERGIES ALLERGIES OR HAD REACTION TO: Narcotics (codeine, morphine, Vicodin, Percocet, etc. Latex Soy Eggs Do you have any other known allergies? List any other allergies: YES NO SYMPTOMS: check the box if you currently have or had any of the following Alzheimer s Heart problems Parkinson s Anemia Heart surgery Pneumonia Angina pectoris Heart valve damage Premature birth Anxiety disorder Hepatitis (A, B,C Psychiatric disorder Arthritis High blood pressure Restless legs Asthma High cholesterol Rheumatic Fever Bleeding disorder HIV+ Scarlet Fever Bleeding tendency Increased fatigue Seasonal allergies Blood disorders Infectious mononucleosis Seizure disorder Blood transfusion Irregular heart beat Sexual dysfunction Bronchitis Irritable bowel Sexually transmitted diseases Bruise easily Jaundice Sinus problems Cancer Joint disease Sleep apnea Cardiac pacemaker Kidney disease Sleep with head elevated Chest pain/angina Liver disease Snoring Chronic fatigue Low blood pressure Stomach ulcers/acid reflux Cold sores/fever blisters Lung disease Stroke Colitis Malaise Swollen ankles Contact lenses Menopause Thyroid disease Cough Mitral valve prolapse Tuberculosis Gallbladder trouble Nasal stuffiness Tumors or growths Glaucoma Night sweats Ulcer Heart attack(s Osteonecrosis Unexplained weight loss Heart murmur Osteopenia Other TREATMENT What is your impression of the type of treatment you need? orthodontics only lower jaw surgery upper jaw surgery upper and lower jaw surgery cosmetic surgery joint surgery sleep apnea surgery cleft repair surgery How many surgical opinions have you obtained? How many orthodontic opinions have you obtained? Have you had previous bite treatments to help solve your problems (crown, bridge, implants or dentures?... Y N How many times have you had orthodontics?... Never 1x 2x 3x 4x more How many times have you had jaw surgery?... Never 1x 2x 3x 4x more Was your bite correct after treatment(s?... Y N Were your problems adequately addressed?... Y N Did your bite relapse or change after treatment(s?... Y N Have you worn dental splint(s?... Never 1x 2x 3x 4x more Have you had joint surgery? arthrocentesis arthroscopy open joint surgery... Y N ORTHODONTIC DENTAL TREAMENT SUGGESTIONS: Has your dentist/orthodontist suggested orthodontia treatment? Y N orthodontia will be placed I am in orthodontic treatment?... Y N orthodontia was placed ORTHODONTIC RECOMMENDATIONS: Extraction of upper teeth... Y N Extraction of lower teeth... Y N Elastics (rubber bands... Y N Roof of the mouth appliance (expander... Y N Functional appliances... Y N Headgear... Y N Page 3

4 TMJ, MUSCLE, AND JOINT CHANGE HISTORY TMJ HISTORY Do you hear clicking sounds in front of your ear(s?... Y N R L Past Present Do you hear popping sounds in front of your ear(s?... Y N R L Past Present Do you hear grinding sounds in front of your ear(s?... Y N R L Past Present Do you have pain in front of your ear(s?... Y N R L Past Present Does your jaw deviate to one side when you open?... Y N R L Past Present Do you have decreased jaw opening?... Y N R L Past Present Does your jaw get stuck open?... Y N R L Past Present Does your jaw get stuck closed?... Y N R L Past Present When are your symptoms worse?... AM PM No difference MUSCLE HISTORY Do you have pain in the cheek area?... Y N R L Past Present Do you have pain in the temples?... Y N R L Past Present Do you have pain behind your jaw?... Y N R L Past Present Do you have neck aches or backaches?... Y N R L Past Present Do you have headaches?... Y N R L Past Present Do you get migraines?... Y N When are your symptoms worse?... AM PM No difference Do you have to posture your jaw to be comfortable?... Y N Do you clench your teeth during the day?... Y N Do you grind your teeth in your sleep?... Y N Are you in an emotional or stressful period of your life?... Y N JOINT CHANGE HISTORY Has your bite changed?... Y N Has your chin moved backwards?... Y N Have your teeth begun to hit unevenly?... Y N Do you bite your tongue or rest your teeth on your tongue?... Y N Do you have a tongue thrust habit?... Y N Have you had recent dental treatments?... Y N Have you worn a splint?... Y N Have you had an injury to your face, head, neck or jaw?... Y N Are any of your joints (arms, legs, feet, hands, back or fingers painful, swollen, or stiff?... Y N Does anyone in your family (immediate, aunts, uncles, cousins have arthritis?... Y N Are your joints hyper-mobile, double jointed, or hyper-flexible?... Y N How do you control your head, neck, and TMJ symptoms? cold packs heat physical therapy diet change anti-inflammatories pain medication steroids limited jaw movement injections into joint injections into muscle other Have you had treatment for your head, neck, and TMJ symptoms? physical therapist TMJ specialist pain clinic oral surgeon orthodontist general dentist ENT neurologist splint TMJ surgery occlusal reconstruction orthodontic care equilibration physical therapy jaw surgery arthrocentesis open joint surgery arthroscopy other Page 4

5 PATIENT MOTIVATION QUESTIONNAIRE Patients often request changes in their bites or faces, relief from pain, or discomfort. Please help us understand your problem by checking the following information: please be specific by checking all words that apply (more, less, forward, backward, longer, shorter, etc.: TEETH: How would you want your teeth to be changed? Straighten my front teeth... upper lower Straighten my back teeth... upper lower Make my upper front teeth... longer shorter Move my upper teeth... forward backward Move my lower teeth... forward backward Move the midline of my upper front teeth to the... left right Move the midline of my lower front teeth to the... left right Make the line of the upper front teeth more level... yes no Comments FACE: What would you want to change about your facial appearance? Reduce the sag under my lower jaw... yes no Move my chin... forward backward Move my chin to center it... left right Move my upper lip... forward backward Move my lower lip... forward backward Move the area around my nose... forward backward Make the profile of my nose... longer shorter Move the area under my eyes... forward backward Make my cheekbones... larger smaller When smiling I want my teeth to show... more less When smiling I want my gums to show... more less When my teeth touch make my lips... closer together farther apart Reduce the strain when I close my lips... chin lips More volume to my lips... yes no More defined jaw line... yes no Reduce lines and wrinkles... yes no Make my upper face... narrower wider How much time do you spend thinking about your appearance and/or bite? never rarely often all the time Comments TMJ OR MUSCLE SYMPTOMS: Where would you want to have your pain or discomfort reduced? Please be specific about the location and mark right, left, or both if it applies. In the front of my ears... right left Above my ears (temples... right left Below my ears (behind jaw... right left In my ears... right left In my neck... right left Comments Page 5

6 Do you fall asleep during the day?... Y N Do you have high blood pressure?... Y N Do you have restless legs while lying in bed?... Y N Have you fallen asleep while driving?... Y N Do you have disrupted sleep?... Y N Do you have an irregular heartbeat?... Y N Do you urinate frequently during the night?... Y N Do you suffer from depression?... Y N Do you snore heavily at night?... Y N Do you have headaches when you wake up?... Y N AIRWAY HISTORY Do you kick or poke your partner while sleeping?... Y N Has anyone seen you stop breathing during sleep?... Y N Do you take sedative type medication?... Y N Have you had a recent weight gain?... Y N Do you have difficulty breathing through your nose?.. Y N Do you have speech clarity problems?... Y N Do you have difficulty closing your lips?... Y N Do you have dry mouth problems?... Y N Do have ADHD?... Y N How do you get to sleep? alcohol beverages medications sedatives sleep on back sleep on side sleep upright sleep with special pillow other Have you had treatment for sleep apnea? CPAP machine dental appliance nasal surgery soft palate surgery weight loss other EPWORTH SLEEPINESS SCALE How likely are you to doze off or fall asleep in the following conditions, in contrast to feeling just tired? This refers to your usual way of life in recent times. Use the following scale to choose the most appropriate number for each situation: 0 = would never dose or sleep 2 = moderate chance of dozing or sleeping 1 = slight chance of dozing or sleeping 3 = high chance of dozing or sleeping CONDITION CHANCE OF DOZING OR SLEEPING Sitting and reading Watching TV Sitting inactive in a public place Being a passenger in a motor vehicle for an hour or more Lying down in the afternoon Sitting and talking to someone Sitting quietly after lunch (no alcohol Stopped for few minutes in traffic while driving TOTAL SCORE (add the numbers, this is your Epworth score I certify that I have read and I understand the questions throughout this questionnaire. I acknowledge my questions, if any, about the inquiries set forth throughout this questionnaire have been answered to my satisfaction. I will not hold my doctor, or any other member of his/her staff responsible for any errors or omission that I have made in the completion of these forms. X X Signature of patient (Patient or Guardian if Minor Page 6

7 INSURANCE INFORMATION Student:... No Yes Full-Time Part-Time School Marital Status:... Married Divorced Single Widow Legally Separated Employed:... Full-Time Part-Time Retired Not Employed Do you belong to a PPO? Yes No (see below for explanation Do you have Medicare? Yes (see below for explanation No The doctors are out of network with all carriers. You must have a PPO policy to allow for any possible reimbursement. We do not accept Medicare, Tricare, MedicAid, Kaiser EPO, and HMO insurance carriers. PRIMARY MEDICAL INSURANCE COMPANY: Employer Business Address City State Zip Business Telephone ( Plan Insurance Company Name I.D. # Insurance Address City State Zip Group # Insured Party Relation Birth Sex M F S.S. # Telephone ( SECONDARY MEDICAL INSURANCE COMPANY: Employer Business Address City State Zip Business Telephone ( Plan Insurance Company Name I.D. # Business Address City State Zip Group # Insured Party Relation Birth Sex M F S.S. # Telephone ( FEES & PAYMENT Insurance is considered a method of reimbursing the patient for fees paid to the doctor and is not a substitute for payment. It is your responsibility to pay any deductible amount, co-insurance, or any other balance not paid for by your insurance company. I hereby authorize my insurance benefits to be paid directly to the named doctor(s. Signature of patient (Patient or Guardian if Minor Signature of financially responsible party Print name (Patient or Guardian if Minor This signature on file is my authorization for the release of information necessary to process my claim to insurance carriers or to forward my records to doctors involved with my care. Signature of patient (Patient or Guardian if Minor Print name (Patient or Guardian if Minor Page 7

8 AUTHORIZATION FOR RELEASE OF MEDICAL/FINANCIAL INFORMATION Patient Name DOB Age Please indicate below those you authorize to receive your protected health information (spouse, parents, family member or significant others: ( Name Phone Number Relationship ( Name Phone Number Relationship ( Name Phone Number Relationship I authorize above named individuals to have access to my medical/financial information. Please understand this information will only be given to or discussed with those you have indicated here. Signature