Patient Registration. Patient Information TODAY'S DATE. Chart ID: First Name ID: Other Dentists if applicable. Other Physician Name

Transcription

1 Patient Registration ID: Chart ID: First Name Other Dentists if applicable Other Physician Name Last Name TODAY'S DATE Middle Initial Whom may we thank for referring you to our practice? Responsible Party First Name Street Address City, State, Zip (If someone other than the patient) Last Name Middle Initial Home Phone Work Phone Ext: Cell Phone Birth Date Soc Sec # Driver License Patient Information Street Address City, State, Zip Home Phone Work Phone Ext: Cell Phone Male Female Married Single Divorced Separated Widowed Birth Date Soc Sec # Driver License Spouse Name Occupation Employer Name Employment Status Full Time Part Time Retired Student Status Full Time Part Time Medicaid ID Employer ID Carrier ID Preferred Dentist Preferred Pharmacy Preferred Hygienist Height Feet Weight Inches

2 Version: SLPQV2 Sleep Consultation OFFICE USE Patient ID: NAME: First Middle Initital Last DATE OF BIRTH: MALE FEMALE TODAY'S DATE Number Frequency Intensity #1 = the most severe symptom TMD / PAIN COMPLAINTS Difficulty Swallowing Dizziness Facial Pain Headaches Jaw Clicking Jaw Locking Jaw Pain Limited Mouth Opening Migraines Morning Head Pain Morning Hoarseness Neck Pain Nocturnal Teeth Grinding Pain when Chewing Number #1 = the most severe symptom Frequency 1-4 Intensity 1-10 Ringing in the Ears SLEEP BREATHING COMPLAINTS 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 Sleepy while Driving Witnessed Apneic Events Other - Write in: Patient Signature Date Page 1

3 THE EPWORTH SLEEPINESS SCALE How likely are you to doze off or fall asleep in the following situatons? Check one in each row: 0 No chance of dozing 1 Slight chance of dozing 2 Moderate chance of dozing 3 High chance of dozing Sitting and reading Watching TV Sitting inactive in a public place (i.e. a theater or a 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 quitely after a lunch without alcohol In a car, while stopping for a few minutes in traffic Total Score: (Add columns 0-3) FATIGUE SCALE During the past week: I felt fatigued and had less motivation I felt fatigued and did not desire to exercise No << >> Yes I felt fatigued often.... I felt fatigue that interfered with my physical functioning I felt fatigued which caused me frequent problems I felt fatigued which prevented sustained physical functioning I felt fatigued and couldn't carry out certain duties and responsibilities Fatigue was among my three most disabling symptoms Fatigue interfered with my work, family or social life Total Score: Patient Signature Date Page 2

4 Berlin Questionnaire Sleep Evaluation 1. Complete the following: Height Weight 7. How often do you feel tired or fatigued after your sleep? 2. Do you snore? yes no don't know If you snore: Your snoring is? How often do you snore? 5. Has your snoring ever bothered other people? 6. slightly louder than breathing as loud as talking louder than talking very loud. Can be heard in adjacent rooms yes no (Answer questions 3-6) Has anyone noticed that you quit breathing during your sleep? During your waketime, do you feel tired, fatigued or not up to par? Have you ever nodded off or fallen asleep while driving a behicle? yes no If yes, how often does it occur? 10. Do you have high blood pressure? yes no don't know (For office use) Scoring Questions: Any answer within the box is a positive response Scoring categories Category 1 is positive with 2 or more positive responses to questions 2-6 Category 2 is positive with 2 or more positive responses to questions 7-9 Category 3 is positive with 1 positive response and/or a BMI > 30 (BMI = Body Mass Index) Final Result: 2 or more possible categories indicates a high likelihood of sleep disordered breathing. Patient Signature Date Page 3

5 SLEEP STUDIES Have you ever had an evaluation at a Sleep Center? Yes No Sleep Center Name and Location Sleep Study Date FOR OFFICE USE ONLY The evaluation confirmed a diagnosis of The evaluation showed mild moderate severe obstructive sleep apnea an RDI of an AHI of during REM Supine Side a nadir SpO2 of T90 Slow Wave Sleep REM Sleep Decreased Decreased None None CPAP Intolerance (Continuous Positive Airway Pressure device) If you have attempted treatment with a CPAP device, but could not tolerate it please fill 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 CPAP does not seem to be effective Pressure on the upper lip causing tooth related problems Latex allergy Claustrophobic associations An unconscious need to remove the CPAP Unable to sleep well Does not resolve symptoms Noisy Cumbersome Other Patient Signature Date Page 4

6 SLEEP HISTORY Previous Diagnosis Yes No Have you been previously diagnosed with Obstructive Sleep Apnea? If Yes, how long ago was it? number Years ago Months ago Days ago Snoring is reported as: Frequency (Choose ONE from below) seldom never daily often Severity (Choose ONE from below) light to moderate moderate to loud light moderate loud Worse during supine sleep Worse following alcohol late at night Sleep: Bruxism Dry mouth Excessive movements Gasping Getting up <number of times> per night Hypnagogic Hallucinations Reading or watching TV before sleeping Restless legs Waking up and having difficulty returning to sleep Dreaming Frequency of nocturnal urination (# of times) Witnessed apneas are: Worse during supine sleep Worse following alcohol late at night Wake Awakens unrefreshed Has morning headaches Has problematic daytime sleepiness Naps (Choose ONE from below) naps daily never naps occasionally naps rarely naps 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 I certify that the medical history information is complete and accurate. Patient Signature Date Date Patient Signature Date Page 6

7 FAMILY HISTORY Has any member of your family had (parent, sibling or grandparent): Yes No Cancer Yes No Obesity Yes No Heart disease Yes No Thyroid trouble Yes No Diabetes Yes No Father snores Yes No High blood pressure Yes No Mother snores Yes No Stroke Yes No Father has sleep apnea Yes No Sleep disorder Yes No Mother has sleep apnea Other SOCIAL HISTORY Tobacco Use: Cigarettes Never Smoked Current Smoker Quit # of packs/day When did you quit? # of years Other Tobacco: Pipe Snuff Cigar Chew Alcohol Use: Do you drink alcohol? Yes No If yes, # of drinks per week Caffeine Intake: None Coffee/Tea/Soda # of cups per day: Additional: Yes No Regular Exercise I authorize the release of a full report 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 Patient Signature Date

8 Medical History Questionnaire OFFICE USE Patient ID: NAME.TODAY S DATE:. First Middle Initial Last DATE OF BIRTH:. This questionnaire was designed to provide important facts regarding the history of your pain or condition. The information you provide will assist in reaching diagnosis and determining the source of your problem. Please take your time and answer each question as completely and honestly as possible. Please sign each page. LIST ANY MEDICATIONS/SUBSTANCES WHICH HAVE CAUSED AN ALLERGIC REACTION: Y N Antibiotics Y N Latex Y N Sedatives Y N Aspirin Y N Local anesthetics Y N Sleeping pills Y N Barbiturates Y N Metals Y N Sulfa drugs Y N Codeine Y N Penicillin Y N Iodine Y N Plastic Other LIST ANY MEDICATIONS CURRENTLY BEING TAKEN: Medication name Dosage/Frequency Reason MEDICAL HISTORY: Medical condition Allergies Acid reflux Adenoids removed Anemia Arteriosclerosis Arthritis Asthma Autoimmune disorder Bleeding easily Blood pressure - high Blood pressure - low Bruising easily Cancer Chemotherapy Chest pains Chronic cough Chronic fatigue Chronic pain Chronically tired Cold hands and feet Cold sores (Please indicate dates on items marked current or past) Never Current Past date Medical condition Never Current Past Immune system disorder Hepatitis Injury to face Injury to mouth Injury to neck Injury to teeth Insomnia Intestinal disorders Jaw joint surgery Kidney problems Liver disease Low energy Lung disease Meniere s disease Multiple sclerosis Muscular dystrophy Needing extra pillows to help breathing at night Nose bleeds often Osteoarthritis Osteoporosis Pacemaker Patient Signature date Date

9 Medical condition Never Current Past COPD Depression Diabetes Difficulty concentrating Difficulty sleeping Dizziness Emphysema Epilepsy Fainting spells Fast pulse Fatigue easily Fibromyalgia Gall bladder problems General anesthesia Glaucoma Hearing impaired Heart attack Heartburn Heart disease Heart murmur Heart pacemaker Heart palpitations Heart problems Heart valve replacement Hemophilia Hypoglycemia date Medical condition Never Current Past Parkinson s disease Polio Poor circulation Prior orthodontic treatment Prostate problems Psychiatric care Radiation treatment Reactions to lead/mercury Reduced sex desire Rheumatic fever Rheumatoid arthritis Scarlet fever Scoliosis Shortness of breath Sinus problems Sleep apnea Speech difficulties Stroke Swallowing problems Thyroid disorder Tonsils removed Tuberculosis Tumors Ulcers Wisdom teeth (third molar extraction date Other Current Past date Other Current Past date ADDITIONAL MEDICAL HISTORY ITEMS Never Current Past date Recreational drugs HIV/AIDS Never Current Past date LIST ANY SURGICAL OPERATIONS YOU HAVE HAD: Y N Appendectomy Y N Heart Y N Thyroid Y N Back Y N Hernia repair Y N Tonsillectomy Y N Ear Y N Lung Y N Uvulectomy Y N Gallbladder Y N Nasal Y N Periodontal Other Patient Signature Date