Patient Registration



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



info@

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 |Moderate chance of |High chance |

| | |dozing |dozing |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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NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

PLEASE REVIEW IT CAREFULLY.

THE PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT TO US.

OUR LEGAL DUTY

We are required by applicable federal and state law to maintain the privacy of your health information. We are also required to give you this notice about our privacy practices, our legal duties, and your rights concerning your health information. We must follow the privacy practices that are described in this Notice while it is in effect. This Notice takes effect April 14, 2003 and will remain in effect until we replace it.

We reserve the right to change our privacy practices and the terms of this Notice at any time, provided such changes and permitted by applicable law. We reserve the right to make the changes in our privacy practices and the new terms of our Notice effective for all health information that we maintain, including health information we created or received before we made the changes. Before we made a signification change in our privacy practices, we will change this Notice and make the new Notice available upon request.

You may request a copy of our Notice at any time. For more information about our privacy practices, or for additional copies of this Notice, please contact us using the information listed at the end of this Notice.

USES AND DISCLOSURES OF HEALTH INFORMATION

We use and disclose health information about you for treatment, payment, and healthcare operations. For example:

Treatment: We may use or disclose your health information to a physician or other healthcare provider providing treatment to you.

Payment: We may use and disclose your health information to obtain payment for services we provide to you.

Healthcare Operations: We may use and disclose your health information in connection with our healthcare operations. Healthcare operations include quality assessment and improvement activities reviewing the competence or qualification of healthcare professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certification, licensing or credentialing activities.

Your Authorization: In addition to our use of your health information for treatment, payment or healthcare operations, you may give us written authorization to use your health information or to disclose it to anyone for any purpose. If you give us an authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect. Unless you give us a written authorization, we cannot use or disclose your health information for any reason except those described in this Notice.

To Your Family and Friends: We must disclose your health information to you, as described in the Patient Rights section of this Notice. We may disclose your health information to a family member, friend or other person to the extent necessary to help with your healthcare or with payment for your healthcare, but only if you agree that we may do so.

520 A Vincent Street | Stevens Point, WI 54481

Persons Involved in Care: We may use or disclose health information to notify, or assist in the notification of (including identifying or locating) a family member, your personal representative or another person responsible for your care, of your location, your general condition, or death. If you are present, then prior to use or disclosure of your health information, we will provide you with an opportunity to object to such uses or disclosures. In the event of your incapacity or emergency circumstances, we will disclose health information based on a determination using our professional judgment disclosing only health information that is directly relevant to the person’s involvement in your healthcare. We will also use our professional judgment and our experience with common practice to make reasonable inferences of your best interest in allowing a person to pick up filled prescriptions, medical supplies, x-rays, or other similar forms of health information.

Marketing Health-Related Services: We will not use your health information for marketing communications without your written authorization.

Required by Law: We may use or disclose your health information when we are required to do so by law.

Abuse or Neglect: We may disclose your health information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes. We may disclose your health information to the extent necessary to avert a serious threat to your health or safety or the health or safety of others.

National Security: We may disclose to military authorities the health information of Armed Forces personnel under certain circumstances. We may disclose to authorized federal officials health information required for lawful intelligence, counterintelligence, and other national security activities. We may disclose to correctional institution or law enforcement official having lawful custody of protected health information of inmate or patient under certain circumstances.

Appointment Reminders: We may use or disclose your health information to provide you with appointment reminders (such as voicemail messages, postcards, or letters).

PATIENT RIGHTS

Access: You have the right to look at or get copies of your health information, with limited exceptions. You may request that we provide copies in a format other than photocopies. We will use the format you request unless we cannot practicably do so. (You must make a request in writing to obtain access to your health information. You may obtain a form to request access by using the contact information listed at the end of this Notice. We will charge you a reasonable cost-based fee for expenses such as copies and staff time. You may also request access by sending us a letter to the address at the end of this Notice. If you request copies, we will charge you $1.00 for each page, $20.00 per hour for staff time to locate and copy your health information, and postage if you want the copies mailed to you. If you request an alternative format, we will charge a cost-based fee for providing your health information in that format. Contact us using the information listed at the end of this Notice for a full explanation of our fee structure.)

Disclosure Accounting: You have the right to receive a list of instances in which we or our business associates disclosed your health information for purposes, other than treatment, payment, healthcare operations and certain other activities, for the last 6 years, but not before April 14, 2003. If you request this accounting more than once in a 12-month period, we may charge you a reasonable, cost-based fee for responding to these additional requests.

Restriction: You have the right to request that we place additional restrictions on our use or disclosure to your health information. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in an emergency).

Alternative Communication: You have the right to request that we communicate with you about your health information by alternative means or to alternative locations. {You must make your request in writing.} Your request must specify the alternative means or location, and provide satisfactory explanation how payments will be handled under the alternative means or location you request.

Amendment: You have the right to request that we amend your health information. (Your request must be in writing, and it must explain why the information should be amended.) We may deny your request under certain circumstances.

Electronic Notice: If you receive this Notice on our Web site or by electronic mail (e-mail), you are entitled to receive this Notice in written form.

QUESTIONS AND COMPLAINTS

If you want more information about our privacy practices or have questions or concerns, please contact us.

If you are concerned that we may have violated your privacy rights, or you disagree with a decision we made about access to your health information or in response to a request you made to amend or restrict the use or disclosure of your health information or to have us communicate with you by alternative means or at alternative locations, you may complain to us using the contact information listed at the end of this Notice. You also may submit a written complain to the U.S. Department of health and Human Services upon request.

We support your right to the privacy of your health information. We will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services.

Privacy Officer: Jen Gingle

Telephone: 715-341-5001

E-mail: info@

Address: 520A Vincent St. Stevens Point, WI 54481

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