New Patient Forms - TMD Patient

Patient Information

Date of Birth

Sex

Male Female

Primary Phone #

Type of Phone

Home Mobile Work

Email Address

Preferred method(s) of contact:

Phone

Text

Address

Line 2

City

State

Zip

Marital Status

Single Married Separated Divorced Widowed Other

If "Other" please explain:

Emergency Contacts

Emergency Contact Person

Relationship to Patient

Primary Phone #

Type of Phone

Home Mobile Work

Email Address

Add Additional Emergency Contact

Financial Information

Who will be financially responsible for you?

Myself Someone Else

If "Someone Else" please fill out the information below:

Full Name

Relationship to Patient

Primary Phone #

Type of Phone

Home Mobile Work

Email Address

Insurance Policy Information

Do you have medical insurance?

Yes No

If "Yes" please enter your policy information below, beginning with your Primary Insurance Policy.

Add Insurance Policy Information

Additional Information

Please list your preferred pharmacies in order of preference.

Add Pharmacy Information

How did you hear about us?

Medical History

Please check all that apply.

Head "Other"

Eyes "Other"

Nose/Sinuses "Other"

Urinary "Other"

Cardiovascular "Other"

Respiratory "Other"

Digestive "Other"

Skin "Other"

Musculoskeletal "Other"

Endocrine "Other"

Neurologic "Other"

Psychiatric "Other"

Oncology "Other"

Are you allergic to any medications?

Yes No

If "Yes" please list all of your allergies to medications.

Add Medication Allergy

Are you currently taking any medications?

Yes No

If "Yes" please list any medications you are currently taking.

Add Medication

Are you pregnant or nursing?

Yes No

Date of last physical exam:

Please list your healthcare providers, beginning with your primary care physician.

Add Healthcare Provider

Surgical History

Please check all that apply:

Nasal/Sinus Surgery

Adenoidectomy/Tonsilectomy

Cancer Surgery

Back Surgery

Hysterectomy

Hip Replacement

Spinal/Cervical Fusion

Other

If "Other" please explain:

Dental History

Name of current Dental Provider

Date of last dental exam

Please check all that apply:

Dental Implants

Dentures

Jaw Surgery

Night Guard for teeth grinding

Orthodontic (Braces) Treatment

Wisdom Teeth Extracted

Other

If "Other" please explain

Dental work scheduled/in progress:

Major dental work:

TMD Symptoms

Please mark the symptoms that you have had or are currently experiencing, by selecting the location on your head: Left side, Right side, or Both sides.

Head Pain

Ear Related Conditions

Front of the head (Frontal)

Left

Right

Both

Buzzing/Ringing in the ears

Left

Right

Both

Entire Head (Generalized)

Left

Right

Both

Congestion/Stuffiness

Left

Right

Both

Top of the head (Parietal)

Left

Right

Both

Dizziness

Left

Right

Both

Back of the head (Occipital)

Left

Right

Both

Hearing Loss

Left

Right

Both

Temples

Left

Right

Both

Itching in the ear(s)

Left

Right

Both

Facial

Left

Right

Both

Pain deep inside the ear

Left

Right

Both

Jaw Related Conditions

Pain in front/behind the ear

Left

Right

Both

Pain when opening jaw

Left

Right

Both

Eye Related

Pain when closing jaw

Left

Right

Both

Blurred or double vision

Left

Right

Both

Pain while chewing

Left

Right

Both

Lacrimation (excessive water)

Left

Right

Both

Pain with side-to-side movement

Left

Right

Both

Pain in or behind the eye

Left

Right

Both

Pain at rest

Left

Right

Both

Dental Related Conditions

Jaw pops

Left

Right

Both

Pain in upper/lower teeth

Left

Right

Both

Jaw clicks

Left

Right

Both

Clench/Grind teeth

Left

Right

Both

Jaw shifts to left/right when opening/closing

Left

Right

Both

Broken teeth

Left

Right

Both

Jaw has locked open or closed

Left

Right

Both

Inability to move jaw left or right

Left

Right

Both

What is your main concern?

What are the chief complaints for which you are seeking treatment?

When did your symptoms first appear?

What makes your symptoms feel worse?

What helps your symptoms feel better?

History of Trauma

Injury to Head and/or Jaw

Have you ever been in a motor vehicle accident? If yes, please add accident info below.

Yes

Add an Accident

Have you ever had any personal injuries to head or jaw (including, but not limited to blows to the face, falling, sports injury, etc...)? If yes, please add information below.

Yes

Add personal injury

Were you ever hurt while on the job?

Yes

If "Yes" please list all injuries.

Add work injury

Acknowledgement of Receipt of Statement of Privacy Practices

I acknowledge that I have received a copy of the Statement of Privacy Practices for the offices of TMD Sleep Apnea Clinic. The Statement of Privacy Practices describes the types of uses and disclosures of my protected health information that might occur in my treatment, payment for services, or in the performance of office health care operations. The Statement of Privacy Practices also describes my rights and the responsibilities and duties of this office with respect to my protected health information. The Statement of Privacy Practices is also posted in the facility.

TMD Sleep Apnea Clinic reserves the right to change the privacy practices currently described in the Statement of Privacy Practices. If privacy practices change, I will be offered a copy of the revised Statement of Privacy Practices at the time of my first visit after the revisions become effective. I may also obtain a revised Statement of Privacy Practices by requesting that one be mailed or otherwise transmitted to me.

Additional Disclosure Authorization

In addition to the allowable disclosures described In the Statement of Privacy Practices, I hereby specifically authorize disclosure of my Protected Healthcare Information to the person(s) identified below. (I understand that the default answer is "NO". Without indicating "YES" in answer to each individual question, protected health information (PHI) 'cannot be shared with anyone unless otherwise allowed by HIPAA rules.)

Spouse Only

Yes No

Any member of my immediate family (i.e. Children, Siblings, etc...):

Yes No

Any member of my extended family (i.e. Parents, Grandchildren, etc...):

Yes No

Other

Yes No

Other

Authorization of Release

I authorize the release of a full report of examination findings, diagnosis, treatment program, etc., to any referring or treating health care professional. I additionally authorize the release of any medical information to insurance companies for legal documentation to process claims. I understand that I am responsible for all charges for treatment to me regardless of insurance coverage.

Patient's Full Name

Today's Date

Legal Guardian's Full Name (if patient is a minor)

I request that my signature be represented by the above electronic signature and consent to recipients of electronic documents that I sign receiving personal information about me, including my email and IP addresses.

Your information will be encrypted.

New Patient Forms - TMD Patient

Patient Information

Emergency Contacts

Financial Information

Insurance Policy Information

Additional Information

Medical History

Please list your healthcare providers, beginning with your primary care physician.

Surgical History

Dental History

TMD Symptoms

Head Pain

Ear Related Conditions

Jaw Related Conditions

Eye Related

Dental Related Conditions

History of Trauma

Injury to Head and/or Jaw

Acknowledgement of Receipt of Statement of Privacy Practices

Additional Disclosure Authorization

Authorization of Release

Center for TMJ & Sleep Solutions NW