The Epworth Sleepiness Scale

The Epworth Sleepiness Scale

How likely are you to doze off or fall asleep in the following situations?

Choose the most appropriate number for each situation:

0= would never fall asleep

1= slight chance of falling asleep

2= moderate chance of falling asleep

3= high chance of falling asleep

ActivityScore

Sitting and reading_____

Watching TV_____

Sitting, inactive in a public place (theater, meeting, ect.)_____

As a passenger in a car for an hour without a break_____

Lying down to rest in the afternoon when circumstances permit_____

Sitting quietly after lunch without alcohol_____

Sitting and talking to someone_____
In a car, while stopped for a few minutes in traffic_____

Total_____

A score of 9 or above indicates you may be having a problem with daytime sleepiness. Below 9 does not necessarily mean that you do not have a problem. See your healthcare professional for advice if you snore, or have been told that you awake gasping for breath, or if you are sleepy during the day.

NameDate

Personal Information

Date______

Mr. Dr. Mrs. Ms. Miss

Name______

Last First Middle Initial

Age______DOB______Gender: F M SS#______

Height ______Ft. ______In. Weight

Work Ph ______Cell Ph______Email ______

Address ______

City/State/Zip ______

Previous Address ______

(Only if you have been at you current address for less than 3 years)

Employer Name & Address ______

______

Family Physician Name & Address ______

______

Please list any other health care practitioners you have seen in the past 9 months ______

______

Insurance ______

Member Number ______Group Number ______Plan Number ______

Referred By ______

Sleep Screening Questionnaire

This questionnaire has been designed to provide important facts regarding the history of your sleep condition. To assist in determining the source of any problem, please take your time to answer each question as completely and honestly as possible.

What are the primary concerns for which you are seeking treatment?

Please number the complaints with #1 being the most important

____Frequent heaving snoring

____Nighttime choking spells

____Nocturnal (night time) teeth grinding

____Significant daytime drowsiness

____Feeling un-refreshed in the morning

____Jaw pain

____Jaw clicking

______

Patient Signature

____Morning hoarseness

____Facial pain

____Difficulty falling asleep

____Morning headaches

____I have been told that “I stop breathing” when I am asleep

____Gasping when waking up

____Swelling in ankles/feet

______

Date

Have you ever had an evaluation at a sleep center? Yes No

Sleep Center Name ______

Sleep Center Location ______

Continuous Positive Airway Pressure

If you have attempted treatment with a CPAP, but could not tolerate it please check all the following that apply to you:

Mask leaks

I was unable to get the mask to fit properly

Discomfort was caused by the straps and headgear

Disturbed or interrupted sleep was caused by the presence of the device

Noise from the device was disturbing my sleep and/or bed partner’s sleep

CPAP restricted movements during sleep

CPAP does not seem to be effective

Pressure on the upper lip causing tooth related problems

A latex allergy

Claustrophobic associations

An unconscious need to remove the CPAP apparatus at night

Other______

Other Therapy Attempts

What other therapies have you tried for breathing disorders? (Weight loss attempts, smoking cessation for at least one month, surgeries, ect.)

______

Patient Signature______Date______

For Office Use Only

The evaluation confirmed a diagnosis of: Mild Moderate Severe (OSA)

The evaluation revealed an RDI of: ______and an AHI of: ______

Do you snore?

Yes No Don’t know

Your Snoring is?

Slightly louder than your breathing

As loud as talking

Louder than talking

Very loud (can be heard in adjacent rooms)

How often do you snore?

Nearly every day 3-4 times a week

1-2 times a week 1-2 times a month

Never or nearly never

Has your ever bothered other people?

Yes No Don’t know

Has anyone noticed that you quit breathing during your sleep?

Nearly every day 3-4 times a week

1-2 times a week 1-2 times a month

Never or nearly never

How often do you feel tired or fatigued after you sleep?

Nearly every day 3-4 times a week

1-2 times a week 1-2 times a month

Never or nearly never

During your wake time, do you feel tired, fatigued, or not up to par?

Nearly every day 3-4 times a week

1-2 times a week 1-2 times a month

Never or nearly never

Have you ever nodded off or fallen asleep while driving a vehicle?

Yes No

If you answered yes, how often does it occur?

Nearly every day 3-4 times a week

1-2 times a week 1-2 times a month

Never or nearly never

Do you have high blood pressure?

Yes No Don’t know

For Office Use Only

Scoring Questions: Any answer to a question a positive response.

Scoring categories:

Category 1: is a positive with 2 or more positive responses to questions 2-6 ______

Category 2: is a positive with 2 or more positive responses to questions 7-9 ______

Category 3: is a positive with 1 response and/or a BMI>30 (Body Mass Index) ______

Final Result:

2 or more possible categories indicates a high likelihood of sleep disordered breathing

Family History

Have any members of your family (blood kin) ever been diagnosed with:

Heart Disease: Yes No

High Blood Pressure: Yes No

Diabetes: Yes No

Have any immediate family members ever been diagnosed or treated for a sleep disorder:

Yes No Don’t know

Social History

Alcohol consumption: How often do you consume alcohol within 2-3 hours of bedtime?

Never Once a week Several days a week Daily Occasionally

Sedative consumption: How often do you take sedatives within 2-3 hours of bedtime?

Never Once a week Several days a week Daily Occasionally

Caffeine consumption: How often do you consume caffeine within in 2-3 hours of bedtime?

Never Once a week Several days a week Daily Occasionally

Do you smoke:

Yes No

If yes, please enter the number of packs per day or any other description of quantity

______

Do you use chewing tobacco?

Yes No

Important Notice

I authorize the release of a full report of examination findings, diagnosis, treatment programs, etc. to any referring or treating Dentist or Physician. I additionally authorize the release of any medical information to insurance companies or for legal documentation to process claims. I understand that I am responsible for all fees for treatment regardless of insurance coverage.

Patient Signature ______Date______

Medical History

Please answer the following questions to the best of your knowledge:

Anemia ------Yes No

Arteriosclerosis ------Yes No

Asthma ------Yes No

Autoimmune disorder ------Yes No

Bleeding easily ------Yes No

Chronic sinus problems ------Yes No

Chronic fatigue ------Yes No

Congestive heart failure ------Yes No

Current pregnancy ------Yes No

Diabetes ------Yes No

Dizziness ------Yes No

Emphysema ------Yes No

Epilepsy ------Yes No

Fibromyalgia ------Yes No

Frequent sore throat ------Yes No

Gastro Esophageal Reflux Disease (GERD) ------Yes No

Hay fever ------Yes No

Heart disorder ------Yes No

Heart mummer ------Yes No

Heart pacemaker ------Yes No

Heart valve replacement ----- Yes No

Heartburn or sour a taste in your mouth at night ------Yes No

Hepatitis ------Yes No

Injury to ------Yes No

HeadNeckTeeth

FaceFace

Insomnia ------Yes No

Irregular heart beat ------Yes No

Jaw joint surgery ------Yes No

Low blood pressure ------Yes No

Memory loss ------Yes No

Migraines ------Yes No

Morning dry mouth ------Yes No

Muscle spasms or cramps ------Yes No

Needing extra pillows at night to help breathing ----- Yes No

Nighttime sweating ------Yes No

Osteoarthritis ------Yes No

Osteoporosis ------Yes No

Poor Circulation ------Yes No

Prior orthodontic treatment ------Yes No

Recent excess weight gain ------Yes No

Rheumatic fever ------Yes No

Shortness of breath ------Yes No

Swollen, stiff, or painful joints ------Yes No

Tonsillectomy ------Yes No

High blood pressure ------Yes No

Medical History

Please list any medications you are currently taking:

Antacids ------Yes No

Antibiotics ------Yes No

Anticoagulants ------Yes No

Antidepressants ------Yes No

Anti-inflammatory drugs (non-steroid) ---- Yes No

Barbiturates ------Ye s No

Blood thinners ------Yes No

Codeine ------Yes No

Cortisone ------Yes No

Diet pills ------Yes No

Heart Medication ------Yes No

High blood pressure medication ------Yes No

Insulin ------Yes No

Muscle relaxants ------Yes No

Nerve pills ------Yes No

Pain medication ------Yes No

Sleeping pills ------Yes No

Sulfa drugs ------Yes No

Tranquilizers ------Yes No

Other current medications: ______

______

Please list any medications which have caused you an allergic reaction:

Antibiotics ------Yes No

Aspirin ------Yes No

Barbiturates ------Yes No

Codeine ------Yes No

Iodine ------Yes No

Latex ------Yes No

Local Anesthetics ----- Yes No

Metals ------Yes No

Penicillin ------Yes No

Plastic ------Yes No

Sedatives ------Yes No

Sleeping pills ------Yes No

Sulfa drugs ------Yes No

Other Allergies: ______

______

Do you have any allergies to medication? Yes No

If yes, please list: ______

Quintana Dental Practice

Office Policy

Welcome to our practice. We are happy to have the opportunity to provide you with excellent dental services. In order to serve you best, we need you assistance with the following:

1. Please notify us of any changes to your phone number, emergency contact number, and/or Insurance coverage. This will help us in processing your claims and in contacting you regarding appointment changes.
2. Call us 24 hours in advance if you need to cancel or change your appointment. We will call you one (1) to two (2) days in advance to remind you of your appointment. If we do not speak to you, we will leave a message requesting you to contact us. If we do not hear from you, we will not be able to guarantee a scheduled appointment for you. Other patients needing appointments will be given your appointment time. If we do not receive 24 hour notice to cancel your appointment, there will be a $42.00 charge.
3. In the event that you miss two (2) scheduled appointments without 24 hours in advance, we will have the option to dismiss you from the practice and you will no longer be allowed to be seen in the practice. This is always difficult for us to do; however, it is important for you to understand that the dentist and his staff’s time is very valuable and other patients needing emergency care are not able to be seen because we are holding an appointment for you. Therefore, if you do not call to cancel in advance this creates a problem for us and the patients needing care. Out of courtesy to the dentist, staff, and to you, we ask that you help us with this situation by keeping your scheduled appointment. If you must cancel, do so within 24 hours of your scheduled appointment.

My signature below indicates that I have read and understand the Quintana Dental Practice Policy.

______

Patient Signature Date

Quintana Dental Practice

Authorization for Leaving Messages

I give permission to Quintana Dental Practice and his dental staff to leave a message on my answering machine/voice mail regarding my dental care.

Home:YesNo

Work: Yes No

I give permission to Quintana Dental Practice and his dental staff to leave a message regarding my dental care with the listed contact at the current phone number.

Contact Name ______Phone Number______

Patient Name ______

Date of Birth ______

Home Ph ______Cell Ph ______Work Ph ______

Emergency Contact ______

Phone Number(s) ______

______

Patient Signature Date

Financial Policy

We offer several financial options to enable you to receive the proper dental care you deserve. To assist you with the payment plans, we have consulted with three dental financial plans: Care Credit, Wells Fargo, and EZ-Pay Solutions. All three offer reasonable financing and monthly payments. As always, we accept credit cards: MasterCard, Visa, and Discover, personal checks, and cash. Our staff will do their best to help you finance your dental care by doing the following:

1. Submitting pre-treatment estimates for pre-approval to your insurance company, as requested. 2. Discussing treatment options and fees prior to beginning treatment. 3. Providing you with assistance in completing the dental financial applications

Dental Insurance

1. No Dental Insurance will cover 100% of all dental expenses.
2. Your portion, not covered by insurance, is due at the time dental treatment is performed.
3. Please understand that Dental Insurance is a contract between YOU, the patient, and the INSURANCE CARRIER and NOT between the insurance carrier and the dentist. The patient is the responsible party regarding dental fees. We will gladly process your insurance claims for you at no charge, as a courtesy to you.
4. Please be aware that we are only able to estimate your portion due to the fact that we deal with a large number of insurance companies, who periodically make changes within their contracts without notifying our office of these changes.
5. Should insurance fail to pay for services within 45 days, the balance will be transferred to your account. We will provide you with the copies of all documentation we have previously forwarded to your insurance company. Often, the patient has more of an opportunity to get reimbursed than we do. We apologize in advance for any inconvenience. We are sure that in these cases, when payments is delayed, you will be more successful then we will.

CASH OR CHECK Payment is due in full when services are performed. If you pre-pay when the appointment is made or before the treatment has begun, a pre-payment discount of 5% is given. We will gladly extend this courtesy discount since prompt payment helps us reduce both our administrative costs and the cost involved when patients fail to keep their appointments. LATE PAYMENTS Late payments will be assessed a 1.5% charge per month on the outstanding balance or 10% annum. GRADUAL TREATMENT PLANS If you do not have dental insurance and are on a budget, we can plan the completion of your dental treatment by spreading your appointments over several months or years. We will arrange to begin the most urgent services first, and then prioritize the remainder of the needed treatment, to be performed at a later date. ACCOUNTS SENT TO COLLECTON We always regret when we turn accounts over to collections, however, should this be the case, a $50.00 administrative fee will be automatically assigned to the account and a 1.5% fee assessed monthly. PAYMENTS I understand that I responsible for paying all co-pays and deductibles at the time treatment services are rendered. ______(please initial). I choose to utilize the following form of payment for my dental services: (Please check all that apply)

Check Credit Card Cash Dental Financing (Care Credit)

______Patient Name (Please print) Date

______Patient Signature

Notice of Privacy Practices

THIS NOTICEDESCRIBED HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIED IT CAREFULLY.

The Health Insurance Portability & Accountability Act of 1996 (HIPAA) requires all health care records and other individually identifiable health information used or disclosed to us in any form, whether electronically, on paper, or orally, can be kept confidential. This federal law gives you, the patient, significant new rights to understand and control how your health information is used. HIPPA provides penalties for covered entities that misuse personal health information. As required by HIPAA, we have prepared this explanation to maintain the privacy of your health information and how we may use and disclose your health information.

Without specific written authorization, we are permitting to use and disclose your health care record for the purpose of treatment, payment and health care operations.

Treatment means providing, coordinating, or managing health care related services by one or more health care providers. For example, we may need to share information with other providers or specialists involved in the continuation of your care.

Payment means such activities as obtaining reimbursement for services, confirmed coverage, billing or collection activities, utilization review. For example, we disclose treatment information when billing a dental plan for your dental services.

Health Care Operations include the business aspect of running our practice. For example, patient information may be used for training purposes, or quality assessment.

Unless you request otherwise, we may use or discharge health information to a family member, friend, or other personal representative to the extent necessary to help your healthcare or with the payment for your healthcare. In addition, we may use your confidential information to remind you of appointments by sending reminder postcards and/or leaving messages at home and/or work. Any other uses and disclosures will be made only with your written authorization. You may revoke such authorization in writing and we are required to honor and abide by that written request, except to the extent that we have already taken actions relying on your authorization.

You have certain rights in regard to your protected health information, which you can exercise by presenting a written request to Privacy Officer at the practice address listed below:

The right to request restrictions on certain uses and disclosures of protected health information, including those related to disclosures to family members, other relatives, close personal friends, or any personal friends, or any other person identified by you. We are however, not required to agree to a requested restriction. If we do agree to a restriction, we must abide by it unless you agree in writing to remove it.

The right to request to receive confidential communication of protected health information from us by alternative means or at alternative locations.

The rights to access, inspect, and copy your protected health information.

The right to request an amendment to your protected health information

The right to receive an accounting of disclosure of protected health information outside of treatment, payment, and health care operations.

The right to obtain a paper copy of this notice from us upon request.

We are require by law to maintain the privacy of your protected health information and to provide you with notice of our legal duties and privacy practices with respect to protected health information.

This notice is effective as of 4/14/2003 and we are required to abide by the terms of the Notice of Privacy Practices currently in affect. We reserve the right to change the terms of our Notice of Privacy Practices and to make new provisions effective for all protected health information that we maintain. Revision to our Notice of Privacy Practices will be posted on the effective dates and you may request a written copy of the Revised Notice from this office.

You have the right to file a formal, written complaint with us at the address below, or with the Department of Health & Human Services, Office of Civil Rights, in the event your privacy rights have been violated. We will not retaliate against you for filing a complaint.