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PATIENT HEALTH HISTORYPlease fill out this form thoroughly. The information listed will be entered into your chart in our electronic medical records system. You are welcomed to a copy of the report.Full Name: _______________________________Date of Birth: ________________________Who referred you to us? ___________________________________________________________Primary Care Physician:____________________________________________________________Dentist: _______________________________________________________________________________Pharmacy: _______________________________Pharmacy Phone: ______________________CURRENT MEDICATIONS:Are you currently taking any prescription or over-the-counter medications?□ No □ Yes If yes, please list below and include dosages.Medication NameDosageHow often taken?MEDICATION ALLERGIES:Are you allergic to any medications? □ No □ Yes If yes, please list below.Name of MedicationType of reactionSurgeries:Have you ever had any type of surgery? □ No □ Yes If yes, list surgeries & dates of surgery.Type of surgeryDate of surgeryType of surgeryDate of surgeryDo you now have or ever had any of the following?If you answer yes, Dr. Tamez will discuss with you in detail during his time with you.SymptomYesNoMouth breathing □□ mild moderate severeDo you feel tired during the day?□□ mild moderate severeHistory of nasal trauma? □□ Are you able to breathe well through your nose?□□ Nasal congestion□□ mild moderate severeBad breath□□ mild moderate severeDrooling□□ mild moderate severeSnoring□□ mild moderate severeHow long does it take you to get to sleep?Minutes? __________ Hours? _____________Frequent waking at night□□ how many times? ____Tossing and turning at night□□ mild moderate severeLeg kicking □□ mild moderate severeNight sweats □□ mild moderate severeSleep walking or talking □□ how often? __________Nightmares □□ how often? __________Vivid Dreams □□ how often? __________Sleep Paralysis□□ how often? __________Bed wetting (after the age of 5)□□ how often? __________Were you able to breast feed as an infant?□□ Are you currently trying to get pregnant or□□how long? have you had problems getting pregnant?Sleep study □□ when? ______________Grinding or clenching teeth (day or night?)□□ mild moderate severeJaw discomfort/TMJ (day or night?)□□ mild moderate severeNail biting□□ mild moderate severeThumb sucking (day or night?)□□ mild moderate severeUse of pacifier? If so, until what age?□□ age? ______________Tongue thrusting (day or night?)□□ mild moderate severeOrthodontic work (braces, expander?)□□ at what age? ________Picky eating (applies to children only)□□ mild moderate severeAttention deficit issues/focusing issues□□ mild moderate severeHyperactivity □□ mild moderate severeObsessive Compulsive complaints□□ mild moderate severeSensitivity to sounds □□ mild moderate severeSensory or Autism Spectrum Disorder□□ mild moderate severeMoodiness □□ mild moderate severeSpeech Issues □□ mild moderate severeErectile dysfunction□□ mild moderate severeDecreased libido□□ mild moderate severeHeadaches□□ how often? __________Height and weight (applies to children only)percentile of height/weight _____________Recurrent sinus infection □□ how often? __________Ear infections □□ how often? __________Ears clogged/popping during air flights□□ how often? __________Ear pressure □□ how often? __________Popping in ears□□ how often? __________Itchy ears□□ how often? __________Itchy eyes□□ how often? __________Do you strain to focus your eyes?□□ mild moderate severeThroat infections□□ how often? __________Have you been allergy tested?□□If so, have you have had allergy shots?□□Bleeding or family history of bleeding disorder? □□017780Patient Partnership PlanDear Patient,Welcome to our practice. Dr. Tamez is committed to providing you with the care and service that you expect and deserve. Achieving your best possible medical outcome requires a “partnership” between you and your doctor. As our “partner in health,” we ask you to help us in the following ways:Schedule Visits as Recommended by My DoctorI understand that my doctor will explain to me my treatment plan in detail. I will schedule the visits pertaining to my treatment and other physician specialists as recommended by my doctor. I understand that by following the treatment plan as outlined, it will enable me to obtain the best medical outcome.Keep Follow-up Appointments and Reschedule Missed AppointmentsI understand that Dr. Tamez is committed to providing the highest level of care to his patients. A missed appointment leaves an empty slot that could have been used by a patient in need of medical care. Not canceling an appointment in a timely fashion is unfair to other patients and prevents Dr. Tamez from providing the type of medical care he takes pride in. A missed appointment, no-show, occurs when a patient fails to give notice that the appointment cannot be kept.When a new patient fails to keep an appointment, the referring physician will be notified. The appointment will be rescheduled once upon request, but after a second no-show, the appointment will only be rescheduled at the request of the referring physician.For established patients, a missed appointment will be rescheduled upon request. A second missed appointment within 12 months, may result in being dismissed from the practice. IF YOUR APPOINTMENT IS NOT CANCELED WITHIN 48 HOURS OR IF YOU NO SHOW, A FEE OF $50.00 WILL BE CHARGED TO YOUR CREDIT rm My Doctor if I Decide Not to Follow His Recommended Treatment PlanI understand that after examining me, Dr. Tamez may make certain recommendations based on what he feels is the best for my condition. This might include but is not limited to prescribing medication, referring me to a specialist, ordering test and/or recommending surgical intervention. I understand that not following my treatment plan can have a negative effect on my overall outcome. I will let my doctor know whenever I decide not to follow his recommendations so that he may fully inform me of any risks associated with my decision to delay or refuse treatment.Thank you for your partnership. As our patient, you have the right to be informed about your healthcare. We invite you, at any time, to ask questions, report symptoms, or discuss any concerns you may have. If you need more information about your health or condition, please ask.__________Patient SignatureDate Physician Signature190500421830500171450508170485087058507048508841740 ................
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