New Patient Paperwork - Tired of CPAP. Midwest Dental Sleep Center ...


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New Patient Paperwork - Tired of CPAP. Midwest Dental Sleep Center ...

  1. 1. <ul><li>Dear PatientWe are looking forward to your upcoming visit. If you have the opportunity, it is helpful to bring the following:1. A copy of your medical insurance card2. A copy of your "diagnostic sleep study" (can be faxed) 3. Completed Paperwork  Phone Hours:Mon - Friday:9:00am to 7:00pmOffice Hours:Tues - Friday 9:00am to 7:30pmWhat to expect at your first visit:The visit will last approximately an hour and 15 minutesBenefits will be explained before incurring any fees30 minutes of the visit is spent doing paperworkPatients will be asked to take three X-raysThe doctors exam lasts around 30 minutesWe allow 15 minutes for impressionsPlease feel free to call with any questions.  See you soon!Oak Brook: In Oakbrook Center (Mall) located at Kingery Highway (83) and 22nd. From 355 take 88 toward Chicago. Go to Midwest Rd take a right off ramp. Go to 22nd take a right. Go to Spring Rd take a left (Mc Donald’s). Go to Commericial take a Left. Take a right on mall loop (Cheesecake Factory) take a left on drive entering mall just past Bloomingdales (White Building). Park in parking garage on the right and walk up into mall. Tall professional building straight ahead. Oakbrook Center 120 Professional Building Suite 726 Oak Brook, IL. 60523. 161925133350 </li></ul> <br /> <br />Richard A. Craig, D.D.S.Charles F. Lockhart, D.D.S.Katherine S. Phillips, D.D.S.James J. Hogg, D.D.S.Midwest Dental Sleep Center220 Channahon StreetShorewood, IL 60404Phone: (815) 744-7055Fax: (815) 744-7059Midwest Dental Sleep Center120 Oakbrook CenterProfessional Bldg. Ste 726Oak Brook, IL 60523Phone: (630) 218-1920Fax: (815) 744-7059Midwest Dental Sleep Center150 E. Huron Street Ste. 1103Chicago, IL 60611Phone: (312) 676-9893Fax: (815) 744-7059<br />Dental Sleep Center<br />ACKNOWLEDGEMENT OF RECEIPT OFNOTICE OF PRIVACY PRACTICES<br />**You May Refuse to Sign This Acknowledgement**<br />I, , have received a copy of this office’s Notice ofPrivacy Practices.<br />{Please Print Name}<br />{Signature}<br />{Date}<br />For Office Use Only<br />We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgement could not be obtained because:<br />Individual refused to sign<br />Communications barriers prohibited obtaining the acknowledgement<br />An emergency situation prevented us from obtaining acknowledgement<br />Other (Please Specify)<br />© 2002 American Dental AssociationAll Rights ReservedReproduction and use of this form by dentists and their staff is permitted. Any other use, duplication or distribution of this form by any other party requires the prior written approval of the American Dental Association.<br />RELEASE & RECEIVE<br />Patient’s Name: DOB: Phone: Date: <br />Purpose of Request: Information being exchanged is required in order to initiate oral appliance therapy and for providing excellent continuity of care in the treatment of Obstructive Sleep Apnea and snoring.<br />Authorization to Release: Requests for information will be listed next to the individual provider. I authorize Dental Sleep Center to send regular reports to update all of my health care providers regarding the status and effectiveness of my treatment. These reports will occur with the new patient consultation and follow-up visits (including 6 month and annual). Previous sleep study reports will be released to sleep centers at their request for purposes of interpretation.<br />Time Limit and Right to Revoke: This consent is active as long as I am an active patient with Dental Sleep Center. I am aware that I can revoke or change all or parts of this consent at any time by submitting my request in writing to Dental Sleep Center 7501 Lemont Rd Suite 300 Woodridge, IL. 60517<br />Re-disclosure: The information disclosed by this authorization may be subject to re-disclosure by the recipient and no longer be protected by the health insurance portability and accountability act of 1996. The facility, its employees, officers and physicians are hereby released from any legal responsibility or liability for disclosure of the above information to the extent indicated and authorized within.<br />Sleep Center: I authorize Dental Sleep Center to send reports.I authorize release of the following to DSC:<br />Name: _____________________________________________ Results of Sleep Studies <br /> <br />Street/City/State: ____________________________________ Medical, Family & Social History<br />Phone/Fax: _________________________________________ Progress Notes <br />Sleep Physician: I authorize Dental Sleep Center to send reports.I authorize release of the following to DSC:<br />Name: _____________________________________________ Results of Sleep Studies <br /> <br />Street/City/State: ____________________________________ Medical, Family & Social History<br />Phone/Fax: _________________________________________ Progress Notes <br /> <br />Physician: I authorize Dental Sleep Center to send reports.I authorize release of the following to DSC:<br />Name: _____________________________________________Request for medical records related to <br /> Sleep Apnea <br />Street/City/State: _____________________________________ <br /> Health, Family and Social History<br />Phone/Fax: _________________________________________ <br />Dentist: I authorize Dental Sleep Center to send reports.I authorize release of the following to DSC:<br />Name: _____________________________________________ Request for assessment, past, current and <br /> recommended treatment<br />Street/City/State: _____________________________________ <br /> <br />Phone/Fax: __________________________________________ <br />Other: I authorize Dental Sleep Center to speak with/release insurance status, financial and billing information to:<br />Patient: _____________________________________________Relationship to Patient: __________________<br /> <br />I authorize Dental Sleep Center to leave a voice mail on my FORMCHECKBOX Cell Phone FORMCHECKBOX Home Phone FORMCHECKBOX Work Phone<br />The following Information can be left on voice mail: FORMCHECKBOX Appt. Reminders FORMCHECKBOX Account Info. FORMCHECKBOX Orders FORMCHECKBOX Test Results<br />I authorize Dental Sleep Center to release and request the information as it is indicated above.<br />Patient Signature: _____________________________Date: ___________________<br />Witness Signature: ____________________________ Date: ___________________<br />Please fax information to (815) 744-7059 or mail to: 120 Oakbrook Ctr Professional Building #726 Oak Brook, IL. 60523<br />Today’s Date: ________________Patient Name:_______________________________ Social Security Number: _______________ Patient Phone Number: _______________________ Referred By: ________________________ Patient Address: _____________________________________________________________________Emergency Contact: _________________________ Relationship: ________________________ <br />Sleep Screening Questionnaire<br />For Staff to complete:<br />O Height: ______ O Weight: ______ O BP:_______ O Neck Circumference: _______ <br />INSTRUCTIONS:<br />This questionnaire was designed to provide important facts regarding the history of your sleep condition. To assist in determining the source of any problem, please take your time and answer each question as completely and honestly as possible. Please complete the following with a pen. You may fill in more than one circle per question.<br />CHIEF COMPLAINTS:<br />Without treatment, I experience the following<br />O Snoring O Witnessed apnea O Gasping O Choking O Daytime fatigue O Napping O Drowsy driving O Difficulty focusing and/or concentrating O Forgetful O Irritable, anxious or depressed <br />O Morning headaches/migraine O Snoring affects others O Concerned about my health<br />Duration<br />O Days O Weeks O Months O Years. Please assign a number: ______ <br />Onset <br />O Gradual O Sudden O Uncertain <br />Aggravated by<br />O Alcohol O Prescription medication O Sleeping on back O Sinus/allergy problems O Weight gain O Other:_____________________________________________________<br />Relieved by<br />O Avoidance of alcohol O Avoidance of prescription sedatives O Side sleeping O Sinus/allergy management O Weight loss O Other: _____________________________________________________<br />HISTORY OF PRESENT ILLNESS (Check all that apply)<br />CPAP: <br />Is CPAP Worn now? <br />O NoO Yes Days per week: ___________Hours per night: ___________<br />If not, was CPAP tried at any point: <br />O No O Yes, and<br />Last used: __________ Typical days per week: ___________Typical hours per night: ___________<br />Machine styles<br />O Never Tried O CPAPO BI-PAP O Auto-PAP O tried humidification<br />Mask styles<br />O never tried O nasal pillows O nasal mask O full face mask<br />Sleep Hygiene<br />Sleep Schedule<br />O regular O irregular O disruptions If other than regular please describe: ______________________<br />Environment<br />O comfortable O temperature uncomfortable O bed uncomfortable O noise level too loud<br />Activities<br />O no activities before bed O eating before bed O exercising before bedO working before bed<br />Weight Loss: <br />Insurance companies require patients with a Body Mass Index over 25% to have failed a trial with weight loss<br />Weight Loss Was<br />O Unsuccessful as attempts did not produce weight loss Describe: _____________________________<br />O Successful but did not improve apnea<br />O Unnecessary as my BMI falls under 25% or muscle mass from body building distorts BMI<br />Medication<br />Medication for apnea<br />O never recommended O recommended O tried but not effective O refusedO could not tolerate<br />Surgery<br />Surgery was <br />O never recommended O recommended O refused O not effective O made apnea worse <br />O improved apnea<br />SOCIAL HISTORY<br />Alcohol:O Yes O NoAmount: ______Frequency: ________<br />Nicotine: O Yes O NoAmount: ______Frequency: ________<br />Caffeine: O Yes O NoAmount: ______Frequency: ________<br />Recreational drug use:O Yes O NoAmount: ______Frequency: ________<br />PAST MEDICAL HISTORY<br />asthmaO Yes O Noenvironmental allergiesO Yes O No<br />seasonal allergiesO Yes O NosinusitisO Yes O No<br />nasal fracture repairO Yes O NoorthodonticsO Yes O No<br />high blood pressureO Yes O Nohigh cholesterolO Yes O No<br />chest pain/anginaO Yes O NoHeart attack/Myocardial Infarct O Yes O No<br />congestive heart failureO Yes O NoAtrial fibrillationO Yes O No<br />irregular heart beatO Yes O Noheart diseaseO Yes O No<br />stroke, CVA or TIAO Yes O NohypothyroidismO Yes O No<br />diabetes, type IIO Yes O Noesophageal reflux (GERD)O Yes O No<br />COPD(lung condition)O Yes O Noanxiety disorderO Yes O No<br />depressionO Yes O Nomigraine headacheO Yes O No<br />insomniaO Yes O NofibromyalgiaO Yes O No<br />kidney diseaseO Yes O NocancerO Yes O No<br />infectious diseaseO Yes O Nosickle cell anemiaO Yes O No<br />bleeding disorderO Yes O Noseizure disorderO Yes O No<br />injury to head, neck or jawO Yes O No osteopenia or osteoporosisO Yes O No<br />other: ___________________________________________________________________________________<br />Initials: ______<br />OTHER DURABLE MEDICAL EQUIPMENT <br />______________________________________________________________________________<br />FAMILY HISTORY<br />FatherO alive O deceased O unknown O snoring O sleep apnea O heart disease<br />Mother O alive O deceased O unknown O snoring O sleep apnea O heart disease<br />SiblingsO alive O deceased O unknown O snoring O sleep apnea O N/A O heart disease<br />SURGICAL HISTORY: <br />Please fill in the circle for any surgical procedures you have had, if not listed please write in<br />O Tonsils O Adenoids O Sinus surgery O Deviated septum repaired O Uvula removed<br />O Soft palate removed O Tongue advanced<br />_______________________________________________________________________________<br />_______________________________________________________________________________<br />MEDICATIONS: (Use back of page if necessary)<br />Please list current prescribed and over the counter medications, dosage and reason for taking <br />NameDosageReason for taking<br />______________________________________________________________________________<br />______________________________________________________________________________<br />______________________________________________________________________________<br />_______________________________________________________________________________<br />Please indicate if you have ever taken any of the following medications:<br />O Boniva O Fosamax O Bonefos O Actonel O Zometa O Aredia O Reclast O Didronel O Skelid OAclasta.<br />If you have checked any of the above medications, <br />Are you currently taking the medication? O YesO No<br />How long have you been taking or did you take the medication: ____________<br />REVIEW OF SYSTEMS<br />Dental<br />Gum disease<br />O not present O present, and is <br />O mild O moderate O severe <br />O has been managed O has not been managed O requires management<br />Hygiene visits<br />O attended regularly O attended infrequently O rarely attended O not attended<br />Dental Treatment<br />O has not been recommended O has been recommended, and <br />O has not been completed as advised O is partially completed per recommendation O has been completed<br />Initials: ______<br />Musculoskelatal<br />Jaw Joint Pain (TMJ)<br />O not suspected O suspected O diagnosed O treated O untreated<br />Allergy<br />Sinus congestion<br />O none O left sided O right sided O both Sides <br />Stuffy nose<br />O not present O present, and is <br />O mild O moderate O severe <br />O worse on left O worse on right O on both sides<br />Ear, nose and throat (ENT)<br />Allergies<br />O not suspected O suspected but not confirmed O confirmed with testing <br />O successfully treated O unsuccessfully treated O untreated O use medication O get shots<br />Snoring<br />1=None 2= Heavy Breathing 3= Light Snoring 4= Moderate Snoring 5= Heavy Snoring <br />Rate your snoring: O 1 O 2 O 3 O 4 O 5 Does your snoring affect others?O No O Yes<br />Respiratory<br />Shortness of breath<br />O denied O always present O during the day only O at night only O worse with exertion<br />Cardiology<br />Leg swelling<br />O not present O present in left leg O present in right leg O present in both legs<br />Blood pressure without medication<br />O within normal range O low O high <br />O managed with medication O difficulty managing with medication O not managed <br />Endocrinology<br />Diabetes<br />O not suspected O borderline O suspected O confirmed with testing <br />O controlled O not controlled<br />Psychology<br />Irritability<br />O noO yes O others have reported <br />Depression<br />O denied O suspected O diagnosed O treated O untreated<br />Anxiety<br />O denied O suspected O diagnosed O treated O untreated<br /> <br />Sleep disturbances<br />O none O unable to fall asleep at night O wake up frequently at night O unable to fall back asleep after waking O light sleeper <br />Initials: ______<br />Gastroenerology<br />Heartburn<br />O denied O occasional O frequent O daily O mostly at night<br />Urology<br />Getting out of bed to use the restroom <br />O none O 1x O 2x O 3x O 4 or more<br />Neurology<br />Headaches<br />O denied O confirmed O in the morning onlyLocation: __________________<br />memory loss<br />O none O forget minor things O forget important things O forget occasionally O forget often <br />Constitutional<br />Weight gain<br />O none O minimal O significant O was rapid<br />Weight loss<br />O none O minimal O significant O intentional<br />Fatigue<br />O none O worse in the morning O worse in the evening O lasts all day<br />ALLERGIES:<br />Do you have a nickel allergy: O No O Yes<br />Do you have an allergy to any over the counter or prescription drugs: O No O Yes<br />Do you have any latex or mint allergies: O No O Yes<br />Other allergies: _________________________________________________________<br />HOSPITALIZATIONS: <br />Please list hospitalizations which are unrelated to your surgical history <br />_______________________________________________________________________<br />EPWORTH SLEEPINESS SCALE<br />When untreated, how likely are you to doze off or fall asleep under the following circumstances?<br />Sitting and readingO No chance O Slight chance O Moderate chance O High chance<br />_______________________________________________________________________<br />Watching TV O No chance O Slight chance O Moderate chance O High chance<br />_______________________________________________________________________<br />Sitting inactive in<br />a public placeO No chance O Slight chance O Moderate chance O High chance<br />_______________________________________________________________________<br />As a passenger in a car<br />For 1+ hrs O No chance O Slight chance O Moderate chance O High chance<br />_______________________________________________________________________<br />Lying down for a rest<br />When time permitsO No chance O Slight chance O Moderate chance O High chance<br />_______________________________________________________________________<br />Talking with someoneO No chance O Slight chance O Moderate chance O High chance<br />_______________________________________________________________________<br />Sitting quietly after lunchO No chance O Slight chance O Moderate chance O High chance<br />_______________________________________________________________________<br />In a car while stoppedO No chance OSlight chance O Moderate chance O High chance<br />Initials: ______<br /> Affidavit of Intolerance to CPAP (Continuous Positive Air Pressure) <br />Patient’s Name: <br />I have attempted to use nasal CPAP to manage my sleep disordered breathing (obstructive sleep <br />apnea) and find it intolerable to use on a regular basis due to the following reason (s): <br />CPAP is not effective in controlling my symptoms. <br />I am unable to sleep with the CPAP equipment in place. <br />The noise from the device disturbs my sleep or my bed partner’s sleep. <br />I cannot find a comfortable mask. <br />The mask leaks. <br />I develop sinus / throat / ear / lung infections. <br />I am allergic to materials in the mask and head straps. <br />Claustrophobia <br />I unconsciously remove the CPAP apparatus at night. <br />The pressure of the mask and straps causes tissue breakdown <br />My job and/or lifestyle prevent this form of therapy (e.g. Active Army / National Guard duty) <br />Prior throat surgery made CPAP intolerable. <br />I refuse to try CPAP as my opening treatment.<br />Other________________________________________________________ <br />Because of my inability to tolerate CPAP and my need to control the signs and symptoms of <br />OSA, I wish to use an alternative method of treatment. This form of therapy is oral appliance <br />therapy (OAT). <br />Patient’s Signature: ________________________________Date: ________________<br />Affidavit for Intolerance to Positional Therapy<br />Patient’s Name: Date: <br />Some patients with obstructive sleep apnea only have apnea while sleeping on their back. Positional Therapy is the use of a device that discourages sleeping on your back (supine). A wedge, bolster or ball is typically placed along the spine and held in place with a t-shirt, waist belt or shoulder straps. This object along the spine makes supine sleep impossible or uncomfortable, thereby encouraging side or stomach (prone) sleep. <br />Please choose one of the following statements:<br /><ul><li> FORMCHECKBOX I have tried Positional Therapy and refuse to utilize the device.</li></ul> <br /><ul><li> FORMCHECKBOX I have not tried Positional Therapy, but refuse to use it and would prefer to try an Oral Appliance.
  2. 2. Please indicate which of the following statements apply:</li></ul> FORMCHECKBOX The positional device does not stay in place and therefore does not prevent back sleeping<br /> FORMCHECKBOX The positional device disturbs my sleep <br /> FORMCHECKBOX The positional device does not help as I am still snoring, gasping, choking or sleepy<br /><ul><li> FORMCHECKBOX I refuse to use a positional device because I sleep on my back and cannot tolerate side sleeping exclusively</li></ul> FORMCHECKBOX I refuse to use a positional device; I experience pain while on my side & therefore must sleep on my back<br /> FORMCHECKBOX I refuse to use a positional device; I snore, gasp or choke on my side/back and therefore feel it is not enough<br /> FORMCHECKBOX Other: ______________________________________________________________________<br />Patient Signature: _______________________________________Date: _____________<br />