Patient Forms

Forms

Once an appointment is made, all patients please complete the health history form below. This will need to be completed before your first visit. It is important to fully complete these forms including the mailing addresses of your doctors and dentists.

TMJ/facial pain patients, please download the TMJ/Facial Pain Consent Form. This will need to be completed and faxed to 301-530-8572, mailed, or brought to your first visit.

Sleep patients, please download the Sleep Consent Form. This will need to be completed and faxed to 301-530-8572, mailed, or brought to your first visit.

We request that all patients can either download or just read our NOTICE OF PRIVACY PRACTICES. At the end of our consent form, we ask you to sign where indicated that you acknowledge having been given the opportunity to review it.

TMJ/Facial Pain Consent Form > Click to download

Sleep Apnea Consent Form > Click to download

Notice of Privacy Practices > Click to download

Billing Procedures > Click to download

CPAP Intolerance Affidavit > Click to download

Epworth Sleepiness Scale> Click to download

Personal Representative Access to Information > Click to download

All forms require Adobe Reader to print. Most computers already have this program installed, but if yours does not Adobe Reader is a free download available at http://get.adobe.com/reader/.

REGISTRATION – HEALTH HISTORY FORM

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Name*
First Middle Last
Pronouns
Today's Date
MM slash DD slash YYYY
Date of Birth*
Height
Weight
Address*
Street Address City State ZIP Code
Mobile Phone Number*
Other Phone Number*
Email*
How did you find us?
- Doctor Referral
- Found us on the internet
- Other
If other, please describe below:

Medical Insurance*
Dental Insurance
Referring Doctors*
Referring Doctor and other Doctors you would like to have reports sent to. Please include their full name and address.
Primary Care Physician’s Name, address and phone number

Indicate which of the following treatments you have tried for your sleep problem:
- Dental device
- Medications
- CPAP
- Surgery
- Behavioral therapy
- Other
If other, please describe
List all current and previous medications you have taken for sleep problems:

Epworth Sleepiness Scale: How likely are you to doze off or fall asleep in the following situations, in contrast to just feeling tired? This refers to your usual way of life in recent times. Even if you have not done some of these things recently, try to work out how they would have affected you: Use the following scale to choose the most appropriate number for the situation: 0 = would never doze 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 (theater, meeting, etc.)
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 quietly after a lunch without alcohol
In a car, while stopped for a few minutes in traffic

Do you have jaw problems?
Do you have jaw pain?
Do you have clicking or other noises in your jaw joint(s)?
Do you have difficulty opening or closing your mouth?
Please describe any jaw or face problem(s) that you may have:

Have you ever been evaluated at a sleep center? If Yes, List the Doctors Name:
List ALL doctors you have seen for your sleep problem:
Pharmacy Name and Phone #:
Past Medical Problems, Surgeries, Hospitalizations, and Injuries: List any operations, hospitalizations, or injuries you have ever had.
Allergies (if No Known Allergies type N/A) List all allergies to medications and the reaction you had to any medicine (or any other allergies):

Do you exercise?
- Yes
- No
How many days per week do you exercise?
How long do you exercise each time (on average)?

Family Medical History
Father Age
Father Deceased or Living
Father Medical Problems
Mother Age
Mother Deceased or Living
Mother Medical Problems
Siblings Age
Sibling Deceased or Living
Sibling Medical Problems
Spouse Age
Spouse Medical Problems
Spouse Deceased or Living
Relationship Status
- Single
- Significant other
- Married
- Separated
- Divorced
- Widowed

Highest Level of Education Completed
- GED
- High school
- Vocational
- College
- Graduate
- Other
If Other Please Describe
List the name of the person or person’s you live with and their relationship to you.
What is your current employment status?
Your current or most recent occupation:
Are you on disability?

Do you or have you smoked tobacco?
- Yes
- No
Number of Packs per day:
Previous smoker?
Years smoked:
Any alcohol use?
- Yes
- No
How many drinks per week?
Do you use recreational drugs?
- Yes
- No
Type:
Do you drink Coffee/Tea/Caffeine?
- Yes
- No
Number of Cups or drinks per day:

Do you have any legal action pending related to this pain or any other health issue?
- Yes
- No
If yes, please list the attorney’s name, address, and phone number:

REGISTRATION – HEALTH HISTORY FORM

Step 1 of 14

We Are Here to Help You

(301) 530-8570