Advanced TMD & Dental Sleep Center
DENTAL/SLEEP Patient Registration
Thomas J. Honl DDS MAGD FAACP
520A Vincent Street
Stevens Point, WI 54481
Phone (715) 341-5001 Fax (715) 341-8983
www.adcofsp.com
Today’s Date: ______
Patient Information:
First Name: ______Last Name: ______Middle Initial: _____
Date of Birth ______Male____Female____Age ______Weight ______
Height: Feet __ Inches___Married___Single___ Divorced ____ Separated ____ Widowed ____
Street Address______
City, State, Zip______
Home Phone ______Work Phone ______(Ext)______Cell ______
Email______
(providing your email address allows us to reward you with a gift certificate as a token of our appreciation for patient referrals of your friends or family members- we will not sell or share your email address)
Employer______Occupation______Phone#______
Student Status: Full Time___ Part Time ___
Responsible party:(If someone other than patient)______
(Relationship to patient) ______
Spouse Name ______Date of Birth ______
Spouse Employer ______Occupation______Phone#______
Previous or current Dentist______Phone______
Address or Facility______
Primary Care Physician______Phone______
Address or Facility______
Emergency Contact Name______Relationship______
Home Phone______Cell Phone ______Work Phone ______
When was your last eye exam? ______
If this is the first time you have been to our office:
Purpose of your visit today______
How long since your last dental visit?______
Average hours sleep per night?______
Oral concerns and chief complaints for which you are seeking treatment?
_____Bleeding gums
_____CPAP intolerance
_____Difficulty falling asleep
_____Difficulty swallowing
_____Dizziness/lightheadedness
_____Dry mouth
_____Ear pain/ringing(tinnitus)
_____Eye discomfort/visual disturbance
_____Facial pain
_____Fatigue
_____Frequent heavy snoring
_____Frequent heavy snoring, which affects the sleep of others
_____ Food gets caught in teeth
_____Gasping when waking up/night time choking
_____History of migraines
_____Jaw pain
_____Jaw clicking
_____Jaw locking
_____Jaw popping
_____Limited mouth opening
_____Lumps or ulcers in mouth
_____Marked weight change
_____Morning head pain/tension
_____Neck pain/shoulder pain/tightness
_____Night sweats
_____Offensive breath
_____One-sided face pain
_____Pain when chewing
_____Prior orthodontia (braces etc.)/ teeth extracted______
_____Shortness of breath
_____Significant daytime drowsiness
_____Sinus headache/pain/pressure/congestion
_____Sleepiness while driving
_____Sore gums/throat
_____Teeth grinding/clenching
_____Tooth sensitivity to cold-where?______
_____Tooth sensitivity to hot-where?______
_____Tooth sensitivity to sweet-where?______
_____Unhappy with appearance of teeth
_____Vision problems/eye disturbances
_____Wake with headaches AM___PM___
_____Witnessed apneic events
Medical History Questionnaire: Allergens
Yes ___ No ___ Adverse reaction to local anesthetic Yes ___ No ___ Antibiotics
Yes ___ No ___ Aspirin Yes ___ No ___ Barbiturates
Yes ___ No ___ Codeine Yes ___ No ___ Erythromycin
Yes ___ No ___ Iodine Yes ___ No ___ Latex
Yes ___ No ___ Metals Yes ___ No ___ Penicillin
Yes ___ No ___ Plastic Yes ___ No ___ Sedatives
Yes ___ No ___ Sleeping pills Yes ___ No ___ Sulfa Drugs
Other______
Current Medications: Please list below all prescriptions, over the counter medicines, vitamins, herbs, oxygen, inhalers and homeopathic remedies, mg, drops etc.
1. Medication ______Taken for what condition? ______
2. Medication ______Taken for what condition? ______
3. Medication ______Taken for what condition? ______
4. Medication ______Taken for what condition? ______
5. Medication ______Taken for what condition? ______
6. Medication ______Taken for what condition? ______
7. Medication ______Taken for what condition? ______
8. Medication ______Taken for what condition? ______
Medical Condition(s): Please check all that apply
Current___ Past ___ Date ______Acid reflux
Current___ Past ___ Date ______Active TB
Current___ Past ___ Date ______ADD/ADHD
Current___ Past ___ Date ______Adenoids Removed
Current ___ Past ___ Date ______Alzheimer’s/Dementia
Current ___ Past ___ Date ______Angina
Current ___ Past ___ Date ______Anxiety
Current ___ Past ___ Date ______Arthritis
Current ___ Past ___ Date ______Artificial replacements/transplants( hip, knee, etc.)
Current ___ Past ___ Date ______Asthma
Current ___ Past ___ Date ______Atrial Fib/Heart palpitations
Current ___ Past ___ Date ______Autoimmune Disorder
Current ___ Past ___ Date ______Breast feeding
Current ___ Past ___ Date ______Cancer/head/neck other ______
Current ___ Past ___ Date ______Chemotherapy
Current ___ Past ___ Date ______Chronic cough
Current ___ Past ___ Date ______Chronic pain
Current ___ Past ___ Date ______Cold hands & feet
Current ___ Past ___ Date ______Congenital Heart Defect
Current ___ Past ___ Date ______Congestive Heart Failure
Current ___ Past ___ Date ______COPD
Current ___ Past ___ Date ______Depression
Current ___ Past ___ Date ______Diabetes
Current ___ Past ___ Date ______Difficulty sleeping
Current ___ Past ___ Date ______Emphysema
Current ___ Past ___ Date ______Epilepsy/Seizures
Current ___ Past ___ Date ______Excessive thirst
Current ___ Past ___ Date ______Fibromyalgia
Current ___ Past ___ Date ______Hay fever
Current ___ Past ___ Date ______Heart attack
Current ___ Past ___ Date ______Heartburn/Gerd
Current ___ Past ___ Date ______Heart disorder
Medical Condition(s) continued
Current ___ Past ___ Date ______Heart murmur
Current ___ Past ___ Date ______Heart pacemaker
Current ___ Past ___ Date ______Heart valve replacement
Current ___ Past ___ Date ______Hepatitis
Current ___ Past ___ Date ______HIV/AIDS
Current ___ Past ___ Date ______Infective endocarditis
Current ___ Past ___ Date ______Injury to mouth
Current ___ Past ___ Date ______Injury to teeth
Current ___ Past ___ Date ______Insomnia
Current ___ Past ___ Date ______Intestinal disorders
Current ___ Past ___ Date ______Liver disease
Current ___ Past ___ Date ______Low Blood Pressure/High blood pressure
Current ___ Past ___ Date ______Low energy
Current ___ Past ___ Date ______Malignant hyperthermia
Current ___ Past ___ Date ______Meniere’s disease
Current ___ Past ___ Date ______Muscle aches
Current ___ Past ___ Date ______Muscular dystrophy
Current ___ Past ___ Date ______Nasal allergies
Current ___ Past ___ Date ______Osteoarthritis
Current ___ Past ___ Date ______Osteoporosis
Current ___ Past ___ Date ______Pregnant
Current ___ Past ___ Date ______Psychiatric care
Current ___ Past ___ Date ______Radiation treatment/Chemotherapy
Current ___ Past ___ Date ______Raynauds
Current ___ Past ___ Date ______Restless Leg Syndrome
Current ___ Past ___ Date ______Rheumatic arthritis
Current ___ Past ___ Date ______Sleep apnea
Current ___ Past ___ Date ______Stroke
Current ___ Past ___ Date ______Tendency for ear infections
Current ___ Past ___ Date ______Thyroid disorder
Current ___ Past ___ Date ______Tuberculosis
Current ___ Past ___ Date ______Tumors
Other______
Surgical Operations:
Yes___ No ___ Adenoidectomy
Yes ___ No ___ Artificial joints
Yes ___ No ___ Back
Yes ___ No ___ Ear
Yes ___ No ___ Heart
Yes ___ No ___ Jaw Joint
Yes ___ No ___ Lung
Yes ___ No ___ Nasal
Yes ___ No ___ Neck surgery
Yes ___ No ___ Thyroid
Yes ___ No ___ Tonsillectomy
Yes ___ No ___ Uvulectomy
Yes ___ No ___ Periodontal
Yes ___ No ___ UPPP
Yes ___ No ___ Wisdom teeth extracted
Other:______
Family History:
Has any member of your family (parent, sibling, or grandparent)had:
Yes ___ No ___ Cancer
Yes ___ No ___ Heart disease
Yes ___ No ___ Diabetes
Yes ___ No ___ High blood pressure
Yes ___ No ___ Stroke
Yes ___ No ___ Sleep disorder
Yes ___ No ___ Obesity
Yes ___ No ___ Thyroid trouble
Yes ___ No ___ Father snores
Yes ___ No ___ Mother snores
Yes ___ No ___ Father has sleep apnea
Yes ___ No ___ Mother has sleep apnea
ORAL CANCER RISK FACTORS
Do you currently smoke? □Yes □ No
If you have quit smoking, how many years ago did you quit? ______
Do you currently chew tobacco? □Yes □ No
If you have quit chewing tobacco, how many years ago did you quit? ______
How many alcoholic beverages do you consume per week? ______
Do you have a history of drug / alcohol abuse? □Yes □ No
Review of Systems:
Hematologic:
Yes ___ No ___ Anemia
Yes ___ No ___ Bleeding disorders
Yes ___ No ___ Bruise easily
Head, Neck and Facial Pain Questionnaire
Head pain (L= left, R= right, B= both)
____ Entire head (Generalized)
L___ R___ B___ Front of your head (Frontal)
____ Top of the head
L___ R___ B___ Back of your head
L___ R___ B___ In your temples
Jaw pain
L___ R___ B___ Jaw pain-on opening
L___ R___ B___ Jaw pain-while chewing
L___ R___ B___ Jaw pain- at rest
Mouth and Nose related conditions
____ Burning tongue
____ Frequent biting of cheek
Eye related conditions
____ Blurred vision
____ Eye pain
____ Pain or pressure behind the eyes
History of Symptoms
When did the pain or condition first occur? ______
What do you believe is the cause of the pain or condition:
____ motor vehicle accident
____ motorcycle accident
____ work related incident
____ an accident
____ whiplash
Other______
Is there anything that makes your pain or discomfort worse? ______
Is there anything that makes your pain or discomfort better? ______
What other information is important regarding the pain & condition? ______
______
History of Treatment:
1.)Practitioner’s Name:______Specialty: ______
Treatment: ______Approx. Date:______
2.)Practitioner’s Name:______Specialty:______
Treatment: ______Approx. Date: ______
Head Pain History
Pain qualities
Which side are the headaches worse:
___ both sides
___ left side
___ right side
Headache spreads to:
___ the temple
___ the back of the head
___ the forehead
SEVERITY --on a scale of 0-10—
0= no pain 10= worst pain imaginable
____ Jaw pain on a 0-10 pain scale
____ Headaches on a 0-10 pain scale
____ Neck pain on a 0-10 scale
____ facial pain on a 0-10 pain scale
FREQUENCY
____ occasional (0-3/mo)
____ frequent (3-6/mo)
____ constant
When having pain do you experience:
___ Dizziness
___ Double vision
___ Fatigue
___ Nausea
___ Sensitivity to light (photophobia)
___ Sensitivity to noise
___ Throbbing
___ Vomiting
___ Burning
Epworth Sleep Questionnaire:
Using the scale below, circle the most appropriate number for each situation and add up your total score.Would never doze / Slight chance of dozing / Moderate chance of dozing / High chance of dozing
Sitting and reading / 0 / 1 / 2 / 3
Watching television / 0 / 1 / 2 / 3
Sitting inactive in a public place ( a theatre, etc.) / 0 / 1 / 2 / 3
A passenger in a car for an hour without a break / 0 / 1 / 2 / 3
Lying down to rest in the afternoon when circumstances permit / 0 / 1 / 2 / 3
Sitting and talking to someone / 0 / 1 / 2 / 3
Sitting quietly after a lunch without alcohol / 0 / 1 / 2 / 3
In a car while stopped for a few minutes in traffic / 0 / 1 / 2 / 3
Total each line
Bed Partner/Witness Screening Questionnaire:
Obstructive Sleep Apnea
Name:______
Person completing form:______Date:____/____/____
Please answer the following questions as they pertain to your bed partner in the past month.
1. While sleeping, does your partner:
Snore more than half the time?...... Y N DK
Always snore?...... Y N DK
Snore loudly?...... Y N DK
Have “heavy” or loud breathing?...... Y N DK
Have trouble breathing, or struggle to breathe?...... Y N DK
2. Have you ever seen your partner stop breathing during the night?...... Y N DK
3. Does your bed partner ever have snorting or choking episodes during the night?...... Y N DK
4. Does your partner: Tend to breathe through the mouth?...... Y N DK
Have a dry mouth on waking up in the morning?……………… . Y N DK
5. Have you ever experienced your partner:
Grinding their teeth during the night?...... Y N DK
Have twitching or kicking of their legs or arms?...... Y N DK
6. Does your partner:
Wake up feeling unrefreshed in the morning?...... Y N DK
Have a problem with sleepiness during the day?...... Y N DK
7. Has a friend, coworker or supervisor commented that your partner appears sleepy during the day?...... Y N DK
8. Is it hard to wake your partner up in the morning?...... Y N DK
9. Does your partner wake up with headaches in the morning?...... Y N DK
10. Is your partner overweight?...... Y N DK
Consent for Release of Information
I understand that, under the Health Insurance Portability & Privacy Accountability Act of 1996 (HIPPA), I have certain rights to privacy in regards to my protected health information. I authorize the release of any information in my medical records relating to my diagnosis and treatment history to Dr. Thomas J. Honl DDS, to assist in the evaluation of my suitability for treatment. I authorize Thomas J. Honl DDS to release a full report of examination findings, diagnosis, treatment program etc. in order to: conduct normal healthcare operations, obtain payment from third-party payers, and plan my treatment and follow up with other healthcare providers. I additionally authorize the release of any medical information to insurance companies or for legal documentation to process claims.
Receipt of Privacy Polices and Practices
I have received a copy of Thomas J. Honl’s Privacy Polices and Practices and reviewed them prior to giving consent for release of information and treatment. I understand that I may request in writing to restrict how my private information is disclosed to carry out treatment or for payment by a third-party payer.
Change of Insurance Carrier(s) and/ or Coverage
I understand that it is my responsibility to inform Thomas J. Honl DDS of any changes in my insurance carrier and/or coverage. Any charges that are acquired as a result of not informing Thomas J. Honl DDS of these changes are my financial responsibility and must be paid upon the date of service.
Statement of Financial Responsibility
I understand that the office of Thomas J. Honl DDS will do its best to estimate insurance coverage through my dental or medical insurance provider and will submit claims on my behalf. It is the policy of Thomas J. Honl DDS that any deductibles, co-payments and/or account balances are due at the time service is provided. In the event that insurance has lapsed or pays differently than estimated, a statement will be sent to me and it is my responsibility to remit full payment upon receipt. Thomas J. Honl DDS accepts cash, check, credit or debit cards and also offers outside financing options through Care Credit and Springleaf Finance.
TO HELP US UTILIZE YOUR INSURANCE BENEFITS, PLEASE BRING ALL DENTAL AND MEDICAL INSURANCE CARDS TO YOUR APPOINTMENT
I CERTIFY THAT ALL MEDICAL HISTORY / PERSONAL INFORMATION IS COMPLETE AND ACCURATE
Patient / Guardian Signature______Date______
Dentist’s Signature ______Date______
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