WELCOME TO OUR PRACTICE

NEW PATIENT HEALTH HISTORY QUESTIONNAIRE

The information you provide in this packet is vital and will assist the doctor during the review of your symptoms. Please respond to all questions. Questions contained in this questionnaire are confidential and will become part of your healthcare record.

Some of the questions are intended for governmental/statistical purposes only.

Date: *****For Office Use Only*****

PATIENT INFORMATION

_________________________________________________________________________________________________________________________________________________ Patient Last Name First Middle Initial Birthdate Age _________________________________________________________________________________________________________________________________________________ Home Address City State Zip Code _________________________________________________________________________________________________________________________________________________ Height (Feet&Inches) Weight (Pounds) Email Address Marital Status: Married Single Separated Divorced Widowed # of Children______ Ages: ___________________________________________________________ Ethnicity: Non-Hispanic Hispanic/Latino Female Male Race: American Indian/Alaska Native Asian Black Hispanic Native Hawaiian/Pacific Islander White Other __________________________________________ Language: English Spanish French Arabic Chinese Sign Language Other_________________ Education: None Grade 1-8 High School Incomplete High School Completed College Post Graduate Professional Training Other: ______________ Employment: Full Time Part Time Retired Disabled Unemployed Military Student Homemaker _________________________________________________________________________________________________________________________________________________ Patient Occupation Business Name Phone# Business Street Address City State Zip

Chart # ________________ Room# ______________ T ________________ Assistant ______________ P ________________ Shielded ______________ BP ________/________ Pregnant ______________ 02s ________________

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PATIENT TELEPHONE NUMBERS Primary Number ____________________

Home Work Mobile Other _______________________ Mobile Carrier: (for texting): AT&T Sprint Verizon Other________

May we leave a message? YES NO

Alternate Number ____________________

Home Work Mobile Other _______________________ Mobile Carrier: (for texting): AT&T Sprint Verizon Other________

May we leave a message? YES NO

EMERGENCY CONTACT INFORMATION

Please provide contact name in case of an Emergency: _____________________________________________________________________________________________________________________________ YES NO Name of Individual Relationship to Patient Primary Phone Number Leave a Message

TREATMENT FINANCIAL RESPONSIBILITY

Person Responsible for Payment of this Account – Self Other - Please Complete Below: __ Responsible Individual’s Name Relationship to the Patient Date of Birth Home Address (If Different than Patient’s Address) City State Zip ______________________________________________ Primary Phone Number Alternate Phone # May we Leave a Message? YES NO

PRIMARY/MEDICAL INSURANCE INFORMATION

Primary Insurance Company Subscriber ID Group # Insurance Company Phone# Subscriber’s Last Name First Name Relationship to the Patient Date of Birth

ADDITIONAL INSURANCE INFORMATION

Insurance Company Subscriber ID Group # Insurance Company Phone# ______________ Subscriber’s Last Name First Name Relationship to the Patient Date of Birth

HEALTHCARE PROVIDER INFORMATION Provider Name Address City, State, Zip

Code Telephone Do you authorize us to

send your treatment information?

Referring Provider

YES NO

Family Physician

YES NO

Dentist YES NO

Other Provider

YES NO

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TMD RELATED SYMPTOMS

HISTORY OF CURRENT SYMPTOMS – Please provide your chief complaint (s) you seek evaluation of: The severity of pain scale is from 0 to 10: 0 =NO PAIN 1-3 = MILD 4-7 = MODERATE 8-10 =SEVERE AREA OF PAIN LOCATION TIMING

(When does the pain occur?)

DURATION (How long have you had the pain?)

SEVERITY QUALITY (Describe your pain- Stabbing, acute, sharp etc..)

CONTEXT (What Improves or worsens your pain)

Jaw Pain Right Left Both

Upon Awakening As day Progresses ____________________ ____________________

______Days ______ Weeks __________________________________

No Pain Mild Moderate Severe

Dull Sharp Stabbing Acute Shooting Burning _______________________

Facial Pain Right Left Both

Upon Awakening As day Progresses ____________________ ____________________

______Days ______ Weeks __________________________________

No Pain Mild Moderate Severe

Dull Sharp Stabbing Acute Shooting Burning _______________________

Ear Pain Right Left Both

Upon Awakening As day Progresses ____________________ ____________________

______Days ______ Weeks __________________________________

No Pain Mild Moderate Severe

Dull Sharp Stabbing Acute Shooting Burning _______________________

Temporal (Temples) Right Left Both

Upon Awakening As day Progresses ____________________ ____________________

______Days ______ Weeks __________________________________

No Pain Mild Moderate Severe

Dull Sharp Stabbing Acute Shooting Burning _______________________

Frontal Head Pain-Forehead

Right Left Both

Upon Awakening As day Progresses ____________________ ____________________

______Days ______ Weeks __________________________________

No Pain Mild Moderate Severe

Dull Sharp Stabbing Acute Shooting Burning _______________________

Parietal-Top of the Head

Right Left Both

Upon Awakening As day Progresses ____________________ ____________________

______Days ______ Weeks __________________________________

No Pain Mild Moderate Severe

Dull Sharp Stabbing Acute Shooting Burning _______________________

Occipital-Back of the Head

Right Left Both

Upon Awakening As day Progresses ____________________ ____________________

______Days ______ Weeks __________________________________

No Pain Mild Moderate Severe

Dull Sharp Stabbing Acute Shooting Burning _______________________

Jaw Joint Symptoms: (Please check applicable symptom below):

Right Left Both

Other Related Symptoms: (Please check applicable symptom below):

Right Left Both

Jaw locks closed Limited neck movement Jaw locks open Ear buzzing Jaw joint sounds on mouth opening Ear congestion Jaw joint sounds on chewing Hearing loss Jaw joint sounds while at rest Ear stuffiness/Itchiness

Do you experience any associated symptoms? NO YES (Please explain) ____________________________________________________________ What improves your symptoms? ___________________________________________________________________________________________________________________________

***COMPLETE BELOW ONLY IF YOUR SYMPTOMS ARE INJURY RELATED*** Date of Injury: __________________________________________ Date your symptoms first appeared: _______________________________

Auto Injury - Were you the: Restrained Driver Non-Restrained Driver Right Front Passenger Left Front Passenger Right Rear Passenger Left Rear Passenger Pedestrian

Work-Related Injury Other Injury, please identify: _______________________________________________________________________________________ Please explain how the injury occurred: ___________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________________________________________ Did you experience those symptoms before the accident? NO Yes When: ____________________________________________________ Explain prior treatment, if any: _____________________________________________________________________________________________________________________________

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SLEEP RELATED HISTORY Have you been previously diagnosed or treated for a sleep disorder condition? NO YES Identify Below: Obstructive Sleep Apnea Central Sleep Apnea Insomnia Narcolepsy Restless Legs Syndrome Periodic limb movement Other: ___________________________________________ From the list below, check your primary sleep related problem(s) or the symptom(s) that best suits you: Snoring Difficulty falling asleep Difficulty staying asleep Impaired cognition Unusual behavior(s)during sleep Morning headache Tired/sleepy during the day Gasping/choking / Repeated pauses in breathing while sleeping Neck Size ________ Have you ever had a sleep study? NO YES Date of Study: _______________________________Complete Below: Sleep Doctor Name/Sleep Facility Address City State Zip

Code Telephone #

CPAP INTOLERANCE – (Continuous Positive Airway Pressure Device) If you have attempted treatment with a CPAP device, but could not tolerate it please list the reason below: A latex allergy Disturbed or interrupted sleep caused by the presence of

the device

An unconscious need to remove the CPAP apparatus at night I was unable to get the mast to fit properly

Claustrophobic association Mask leaks

CPAP does not seem to be effective Noise from the device disturbing my sleep and/or bed partner’s sleep

CPAP restricted movements during sleep Pressure on the upper lip causing tooth issues

Discomfort caused by the straps and headgear Other: _________________________________________________________

OTHER THERAPY ATTEMPTS RECEIVED FOR YOUR SLEEP CONDITION: What other therapies have you had for breathing disorders? ___________________________________________________________________________ Surgeries _______________________________________________________

Weight Loss Attempts

Smoking Cessation for at least one month Other: _______________________________________________________________

STOP-BANG SLEEP APNEA QUESTIONNAIRE

Please circle appropriate (YES/NO) box below that best describes your situation: STOP

Do you SNORE loudly (louder than talking or loud enough to be heard through closed doors)? YES NO Do you often feel TIRED, fatigued, or sleepy during daytime? YES NO

Has anyone OBSERVED you stop breathing during your sleep? YES NO

Do you have or are you being treated for high blood PRESSURE? YES NO

BANG

BMI MORE THAN 36KG/M2? YES NO AGE over 50 years old? YES NO

NECK circumference >16 inches (40cm)? YES NO

GENDER: Male? YES NO

THE SCORING SECTION BELOW IS TO BE COMPLETED BY THE OFFICE STAFF: TOTAL SCORE

HIGH RISK OF OSA: YES 5-8 INTERMEDIATE RISK: YES 3-4 LOW RISK YES 0-2

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ACTIVE MEDICATIONS: Below, please list any prescribed/over the counter medications and vitamins that you are taking. Medication Strength Unit Amount Frequency Started On Notes/Taken for Example: Lipitor 10 Mg 1 Once Daily 01/10/2010 High Cholesterol 1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

ALLERGIES Do you have any allergies: NO YES - Please list below: Allergy Type Reaction HEALTH AND MEDICAL HISTORY As of today’s visit, are you, or could you be pregnant: NO YES Due Date: Are you currently breastfeeding: NO YES FAMILY HISTORY- Check applicable condition (s) below: CONDITION - FAMILY MEMBER (S) WITH RELATED CONDITION Heart Disease Mother Father Sister Brother Maternal Grandmother

Maternal Grandfather Paternal Grandmother Paternal Grandfather Hypertension Mother Father Sister Brother Maternal Grandmother

Maternal Grandfather Paternal Grandmother Paternal Grandfather Liver Disease Mother Father Sister Brother Maternal Grandmother

Maternal Grandfather Paternal Grandmother Paternal Grandfather Cancer Type:

Mother Father Sister Brother Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandfather

Diabetes Type:

Mother Father Sister Brother Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandfather

Kidney Disease Mother Father Sister Brother Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandfather

Sleep Apnea Mother Father Sister Brother Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandfather

Temporomandibular Disorders Mother Father Sister Brother Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandfather

Other: __________________________ Mother Father Sister Brother Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandfather

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REVIEW OF SYSTEMS: Please circle applicable condition (s) below.

Constitutional/General Cancer Fatigue Fever Sweats None

Eyes Blurred Vision Double Vision Light Sensitivity None

Respiratory Apnea/OSA Asthma Excessive Snoring Shortness of Breath None

Ear, Nose, Mouth, Throat Bleeding Gums Difficulty Swallowing Dry Mouth Facial Numbness Hearing Problems Ringing in the Ears Sore Throat None

Immunologic/Allergic Allergies to Medications Autoimmune Disorders Hay Fever Symptoms HIV Exposure Seasonal Allergies Sinus Pressure None

Musculoskeletal Arthritis Fibromyalgia Joint Pain Joint Stiffness Joint Swelling Muscle Weakness Osteoporosis Rheumatoid Arthritis None

Cardiovascular Blood Clotting Disorders Chest Pains Heart Attack High Blood Pressure Low Blood Pressure Pacemaker Racing/Skipping Heart Beats Swelling of Feet Swelling of Hand None

Gastrointestinal Acid Reflux Bloody Stool Nausea Vomiting None

Hematologic (Blood/Lymphatic) Abnormal Blood Tests Anemia Bleed Easily Bruise Easily Leukemia Swollen Lymph Nodes None

Neurologic Dizziness Headaches Speech Problems Stroke Traumatic Head Injury Tremor None

Genitourinary Blood in Urine, Frequent Urination Renal Disease None

Endocrine Diabetes Heat Intolerance Increased Thirst Unexplained Weight Gain Unexplained Weight Loss None

Psychiatric Anxiety Depression Difficulty Sleeping Thoughts of Violence None

Integumentary (Skin) Changes in Skin Color Dry Skin Hair Loss or Increase Rash None

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SURGICAL HISTORY - Check applicable condition (s) below: Surgery Date Surgery Date Adenoidectomy Rhinoplasty Jaw Joint Tonsillectomy Orthognathic Other:

HEALTH HABITS & SOCIAL HISTORY - Please circle applicable area (s) below: Alcoholic Beverages None Rarely Moderate Daily Recreational Drugs None Rarely Moderate Daily

Caffeine Use None Less than 3 cups/day 3-6 cups/day More than 6 cups/day Exercise None Very Little Moderate Regular Physical Activity None Very Little Moderate Regular Social Activity None Very Little Moderate Regular SMOKING INFORMATION - Please select appropriate status box (s) below: Never a smoker Former Smoker Light Tobacco User Heavy Tobacco User Current Everyday Smoker Current Some Day Smoker

How Many: Date Started: Notes: I report the use of: Cigarettes Cigar Chewing Pipe Hookah

PHARMACY INFORMATION Pharmacy Name: _________________________________________________________________________ Phone Number: Address: ____________________________________________________________________City:_________________________ State: _________ Zip:___________ I, the patient/representative attest to the best of my knowledge, all of the above information is correct. I understand that I must provide at least a 24 business-hour cancellation notice. Otherwise, I will be charged a $50.00 cancelation fee. I understand that I am responsible for all charges incurred for my treatment or my child’s’ treatment regardless of insurance coverage. As a courtesy, my appropriate insurance carrier may be billed for the rendered services. I hereby authorize the release of pertinent health information to the insurance company, or for legal documentation and/or to process claims. I hereby authorize my insurance benefits to be paid directly to Dr. Ghabi A. Kaspo at Facial Pain and Sleep Center, PLC otherwise payable to me, realizing that I am responsible to pay for my treatment, and for the cost share/ non-covered services. I understand that I am responsible for charges/lab fees incurred for the appliance/mouth piece should I fail to present for the appliance insertion appointment. Charges not paid within 45 days will have a service/handling charge of $10.00 per month added to the past due balance on each monthly statement thereafter. If payment is not submitted, I, the undersigned also agree to pay any reasonable attorney fees and costs which may be incurred by Dr. Ghabi Kaspo at the Facial Pain and Sleep Center, PLC in collecting payment for services rendered. I authorize the release of a full report of my records comprising of examination findings, diagnosis, imaging, treatment program, progress notes, etc., to my referring/treating or mutual providers. Copies of my records or x-rays may be released to me or to another party authorized by me upon my timely request and payment of appropriate fees. Signature of Patient/Parent/Guardian Date If patient is a minor, provide name of parent/guardian who is responsible to bring the patient for treatment: _____________________________________________ _________________________________________________________________________________________ Parent/Guardian Printed Name Relationship to Patient Reviewed by: Facial Pain and Sleep Center, PLC _________________________________________________ Date: _____________________________ 2020 Facial Pain and Sleep Center, PLC COPY RIGHT RESERVED