Office of Keerthi Senthil DDS, MS 72027 Desert Drive, Rancho Mirage,CA 92270 (760) 340- 5107 Today’s Date: ___________________ Patient Information. As required by law, our office adheres to written policies and procedures to protect the privacy of information about you that we create, receive or maintain. Your answers are for our records only and will be kept confidential subject to applicable laws. Please note that you will be asked some questions about your medical history in this questionnaire and there may be additional questions or forms concerning your health. This information is vital to allow us to provide appropriate care for you. This office does not use this information to discriminate . Are you completing this form for another person, what is your relationship to that person? Your Name ___________________ Relationship ___________________ Patient Name Last ___________________ Middle ___________________ First ___________________ Home Phone (include area code) ___________________ Mobile Phone (include area code) ___________________ Work Phone (include area code) ___________________ Address ___________________ City ___________________ State ___________________ Zip Code ___________________ Email ___________________ Mailing Address ___________________ Date of Birth ___________________ Sex M __ F __ Height _______ Weight ______ Occupation ___________________ Employer Name, Address ___________________ Marital Status: __ Single __ Married __ Divorced __ Separated Social Security Number Emergency Contact Relationship to Patient ___________________ ___________________ ___________________ Their Home Phone Their Cell Phone ___________________ ___________________ Please tell us how you were referred to this office: Physician Information. Please list all the physicians whose care you are currently under Primary Care ___________________ Telephone ___________________ Address, City, State, Zip ___________________ Specialist Physician ___________________ Telephone ___________________ Address, City, State, Zip ___________________ Medical Area of Specialty ___________________ Insurance Information. I certify that I or my dependents have insurance with the below listed companies and assign directly to XXXXXX Dental all insurance benefits. I understand that I am financially responsible for all charges, whether or not paid by insurance. I authorize the use of my signature on all insurance submissions. Dental Insurer Company Name Name of Insured Their Soc. Sec. # ___________________________ _____________ ______________ Subscriber ID Number Group ID Number ___________________________ _______________ Medical Insurer Company Name Name of Insured Their Soc. Sec. # ___________________________ _______________ ______________ Subscriber ID Number Group ID Number ___________________________ _______________ Secondary Medical Insurance Name _______________ Subscriber ID Number Group ID Number ___________________________ _______________ Medical Questions, general. Please indicate all that apply If you answer YES to any of the first 4 questions, please STOP and see receptionist: * Do you have Diabetes? Yes __ No __ Don't Know __ * Do you have Heart Disease? Yes __ No __ Don't Know __ * Do you have any Artificial Joints or Artificial Heart Valves? Yes __ No __ Don't Know __ * Are you in good health? Yes __ No __ Don't Know __ * Have you ever had Radiation Therapy or Chemotherapy? Yes __ No __ Don't Know __ Are you currently under the care of a physician? Please Name _______________ Any changes to your general health in the last year? Yes __ No __ Don't Know __ Date of last physical exam _______________ If yes, what is the condition being treated? _______________ Have you had a serious illness, operation or been hospitalized in the last 5 years? Yes __ No __ Don't Know __ If yes, what was the illness or problem? _______________ Are you taking or have recently taken prescription or over the counter medications? Yes __ No __ Don't Know __ If yes, please list all including vitamins, natural or herbals preparations and/ or diet supplements or anything else the Dentist should be aware of: _______________ Allergies. Please indicate all those you are or have been allergic to, and if yes please indicate your reaction Local Anesthetics Yes __ No __ Don't Know __ Aspirin Yes __ No __ Don't Know __ Penicillin or Any Other Antibiotics Yes __ No __ Don't Know __ Barbiturates, Sedatives, or Sleeping Pills Yes __ No __ Don't Know __ Sulfa Drugs Yes __ No __ Don't Know __ Codeine or other Narcotics Yes __ No __ Don't Know __ Metals Yes __ No __ Don't Know __ Latex (rubber) Yes __ No __ Don't Know __ Iodine Yes __ No __ Don't Know __ Hay fever /Seasonal Yes __ No __ Don't Know __ Animals Yes __ No __ Don't Know __ Other Yes __ No __ Don't Know __ Has a physician or dentist recommended that you take antibiotics prior to your dental treatment? Yes __ No __ Don't Know __ Name of physician or dentist _______________ Phone _______________ Women Only. Are you: Pregnant? Yes __ No __ Don't Know __ If YES, number of weeks: ________ Taking Birth Control Pills/ Hormone Replace? Yes __ No __ Don't Know __ Nursing? Yes __ No __ Don't Know __ Tobacco, Alcohol, Other. Do you use Controlled Substances? Yes __ No __ Do you use tobacco or nicotine, in any form? Yes __ No __ Do you use Alcohol? Yes __ No __ How interested are you in Stopping? High __ Medium __ Low __ How much in a day ________ Times per week ________ Osteo-, Paget's, Other. Are you taking or scheduled to take either of the medications: Alendronate (Fosamax) or Risedronate (Actonel) for osteoporosis or Paget's disease? Yes __ No __ Don't Know __ Since 2001, were you treated or scheduled to intravenous bisphosphonates (Aredia/ Zometa) for osteoporosis, hypercalcemia or skeletal complications from Paget Yes __ No __ Don't Know __ Conditions, Diseases. Please indicate all that apply __ AIDS or HIV infection __ Alzheimer's Disease __ Anaphylaxis __ Anemia __ Angina __ Arthritis / Gout __ Artificial Heart Valve __ Artificial Joint __ Asthma __ Atherosclerosis __ AutoImmune Disease __ Been told you Stop Breathing __ Been told you Snore __ Blood Disease __ Blood Transfusion __ Breathing Problems __ Bruise Easily __ Cancer __ Cardiovascular Disease __ Chemotherapy __ Chest Pains __ Cold Sores / Fever Blisters __ Congestive Heart Failure __ Consume Alcohol __ Convulsions __ Cortisone Medicine __ Crohn's, Ulcerative Colitis __ Depression __ Diabetes __ Dizziness * ________________________ * ________________________ __ Drug Addiction __ Dry Mouth, Cracked Tongue __ Easily Winded __ Emphysema __ Epilepsy or Seizures __ Excessive Bleeding __ Excessive Thirst __ Fainting Spells / Dizziness __ Frequent Cough __ Frequent Diarrhea __ Frequent Headaches __ Genital Herpes __ Glaucoma __ Had Physician Recommend a Sleep __ Hay Fever __ Heart Attack __ Heart Murmur __ Heart Pacemaker __ Heart Trouble/ Disease __ Hemophilia __ Hepatitis A __ Hepatitis B or C __ Herpes __ High Blood Pressure __ High Cholesterol __ Hives or Rash __ Hypoglycemia __ Irregular Heartbeat __ Jaw Clicking, Locking __ Jaw Joint Pain __ Kidney Problems __ Leukemia __ Liver Disease __ Low Blood Pressure __ Lung Disease __ Mitral Valve Prolapse __ Other Heart (congenital) Defects __ Osteoporosis __ Pacemaker __ Pain in Jaw Joints __ Parathyroid Disease __ Pneumonia __ Psychiatric Care __ Radiation Treatments __ Recent Weight loss __ Renal Dialysis __ Resort to Mouth-Breathing __ Rheumatic Fever __ Rheumatism __ Scarlet Fever __ Shingles __ Sickle Cell Disease __ Sinus Trouble __ Smoker, Tobacco Use __ Spina Bifida __ Stomach / Intestinal Disease __ Stroke * __________________ * __________________ * __________________ __ Study, or had One Performed __ Suffer from Daytime Drowsiness __ Suffer from Nasal Obstruction in Sleep __ Swelling of limbs __ Teeth Grinding * __________________ __ Thyroid Disease __ Tonsillitis __ Tuberculosis __ Tumors or Growths __ Ulcers __ Venereal Disease __ Wake up Un-Refreshed __ Yellow Jaundice Please list any and all Conditions or Diseases you may have, not listed here ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ Dentist's Notes, please keep this space clear ___________________________________________________________ ___________________________________________________________ * Both Doctor and Patient are encouraged to discuss any and all relevant Patient Health issues prior to treatment. I hereby certify that I have read and understand the above and that the information given on this form is accurate. I understand the importance of a truthful health history and that my dentist and staff will rely on this information for my treatment. I acknowledge that my questions, if any, about inquiries set forth above have been answered to my satisfaction. I will not hold my Dentist nor any member of staff, responsible for any action they take or do not take because of errors or omissions that I may have made in the completion of this form. Signature of Patient ____________________ Date ____________________ Signature of Legal Guardian ____________________ Date ____________________ Patient Rights- Access to Your Medical Records You have the right to look at or obtain 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 requested by you unless we cannot practicably do so. Please make this request in writing, to obtain your health information. We will charge a reasonable cost-based fee for expenses such as copies, information for a fee as well. Contact us for further information. Privacy Practices Acknowledgment I, _____________ have received a copy of the Privacy Practices from Keerthi Senthil, DDS, MS Patient Name _______________ Phone _______________ Email _______________ Address _______________ City _______________ State _______________ Zip _______________ Patient Signature _______________ Date _______________ Witness Name _______________ Witness Signature _______________ Date _______________ Consent for Services You have the right as a patient, to be informed about your condition and the recommended dental, medical or diagnostic procedures to be used that you make the decision whether or not to undergo the procedure after knowing the risks involved. This disclosure is meant not to alarm you rather it is simply an effort to make you better informed so you may give or withhold your consent to a procedure. I, _______________ consent to be a patient of Keerthi Senthil, DDS, MS and agree to radiographic and clinical examination. I also understand the following: 1. During the course of treatment, I may undergo procedures in all places of dentistry and medicine, including periodontics (gum treatment and surgery), oral surgery, endodontics (root canals), fixed and removable prosthodontics (crowns, bridges and dentures), implant dentistry, restorative dentistry, temporomandibular disorder treatment, sleep apnea treatment, oral pathology, radiography, and saliva DNA testing. Initials _______________ 2. I will provide a thorough and complete medical history, supply a full list of my medications with dosages, and consent to my dentist communicating with my other medical practitioners to inquire about any aspect of my health history. Initials _______________ 3. No guarantee nor warranty can be made about treatment outcomes, restoration longevity, nor prognosis. I understand that any branch of medicine, including dentistry, can involve unanticipated results. Initials _______________ 4. I will pay in advance any cost of treatment or insurance copayments according to the office's financial policy. I understand that even if an insurance pre-estimate is given or a procedure has been pre-approved, I am responsible for all costs of my insurance does not cover. Initials _______________ 5. My treatment plan may change over time and I will do my best to approach my dental care with optimism and open communication with my dentist, hygienist and dental office staff. Initials _______________ Financial Policy Payment is due when services are rendered. For payment options, you may apply for a payment plan through Care Credit Dental Fee Plan, which must be arranged and approved in advance of your treatment appointment. As a courtesy to our patients who have dental insurance and medical insurance coverage, we will file your claim electronically. Your deductable and co-payment are due the day of service. Any amount exceeding your plan's annual maximum amount is due when service is rendered. Please give our office at least 24 hour's notice to cancel or re-schedule an appointment. A minimum fee of $50.00 will be charged for missed appointments. We appreciate your cooperation, Thank You. Signature ______________ Date _______________ Today’s Date: __________________ Sleep Health Questionnaire Patient Name: Last __________________ Middle __________________ First __________________ Home Phone (include area code) __________________ Work Phone (include area code) __________________ Mobile Phone (include area code) __________________ Address __________________ City __________________ State __________________ Zip Code __________________ Email __________________ Mailing Address __________________ Date of Birth __________________ Sex M __ F __ Height __________________ Weight __________________ Occupation __________________ Employer Name, Address __________________ Marital Status: Single __ Married __ Divorced __ Separated __ Social Security Number Emergency Contact Relationship to Patient __________________ __________________ __________________ Their Home Phone Their Cell Phone __________________ __________________ Have you ever fallen sleep or nodded off while driving? __ Yes __ No 6 Have you ever woken up suddenly with shortness of breath, gasping or with your heart racing? __ Yes __ No 6 Do you feel excessively tired during the day? __ Yes __ No 4 Do you snore or have been told that you snore? __ Yes __ No 4 Have you had weight gain and found it difficult to lose? __ Yes __ No 2 Have you taken medication for, or been diagnosed with high blood pressure? __ Ye __ No 2 Do you kick or jerk your legs while sleeping? __ Yes __ No 3 Do you feel burning, tingling or crawling sensation in your legs when you wake up? __ Yes __ No 3 Do you wake up with headaches during the night or in the morning? __ Yes __ No 3 Do you have trouble falling asleep? __ Yes __ No 4 Do you have trouble staying asleep once you fall asleep? __ Yes __ No 4 Have you been told you stop breathing in your sleep? __ Yes __ No 8 TOTAL SCORE: __________ Risk Level Score Low 0-7 Medium 8-11 High 12-15 Severe 16+ Signs and Symptoms. Please indicate all that apply __ Family History of Snoring or Sleep Apnea __ Stroke/ Heart Disease __ Un-refreshed Sleep __ Depression __ Grind Teeth __ Acid Reflux __ Hypertension __ Snoring __ Diabetes Sleep History. Please indicate all that apply Have you ever been diagnosed with a Sleep Disorder? Yes __ No __ Are you currently using a CPAP machine? Yes __ No __ Do you use your CPAP less than 5 times a week? Yes __ No __ Would you prefer an oral device or appliance? Yes __ No __ Patient’s Signature __________________ Date __________________