Patient Medical (Confidential) Form Page 2
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1
2Dental History
Have there been any injuries to the face, mouth, or teeth?
Yes____
No____
If yes, explain_________________
Have you ever sucked a thumb or fingers?
Yes____
No____
Until what age?________________
Do you have any speech problems?
Yes____
No____
Are you a mouth breather?
While awake?
Yes____
No____
While asleep?
Yes____
No____
Have you been informed of any missing or extra permanent teeth? Yes____
No____
Has an orthodontist been consulted previously?
Yes____
No____
Has either parent had orthodontic treatment?
Yes____
No____
List any musical instruments played:______________________________________________________________________________
Reason for consultation:________________________________________________________________________________________
When was your last dental checkup?______________________________________________________________________________
SLEEP PATTERNS
Use the following scale to choose the most appropriate number for the situation
0= never would doze 1=slight chance of dozing
2= moderate chance of dozing 3= high chance of dozing
Sitting and Reading
0
1
2
3
Sitting inactive in a public place
0
1
2
3
As a passenger in a car for an hour
0
1
2
3
Lying down to rest in afternoon
0
1
2
3
Sitting and talking to someone
0
1
2
3
Sitting quietly after lunch
0
1
2
3
In a car while stopped in traffic
0
1
2
3
Watching TV
0
1
2
3
Other:__________________________ 0
1
2
3
Do you snore while asleep?
YES
NO
IF YOU SCORED HIGHER THAN AN “8” THEN YOU ARE AT RISK FOR SLEEP APNEA—
DR YOREK WILL DISCUSS THIS WITH YOU
Notice of Privacy Practices:
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND
DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW
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 be kept confidential. The federal law gives you, the patient, significant new rights to understand
and control how your health information is used. HIPAA provides penalties for covered entities that misuse personal health information. As
required by HIPAA, we have prepared this explanation of how we are required to maintain the privacy of your health information and how we
may use and disclose your health information. Without specific written authorization, we are permitted to use and disclose your health care
records for the purposes of treatment, payment, and health care operations. Examples are available upon request.
Unless you request otherwise, we may use or disclose health information to a family member, friend, or other personal representative to the
extent necessary to help with your healthcare or with 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 at 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 we have already taken actions relying on your authorization.
For more information about our Privacy Practices, please contact our office.
I have reviewed Dr. Yorek’s Notice of Privacy Practices and understand that more information is available upon request.
I also certify that I have read and understand the above information to the best of my knowledge. The above questions have been answered
accurately; I understand that providing incorrect information can be dangerous to my health. I authorize to release any information, including
the diagnosis and the records of any treatment or examination rendered to my child or me during the period of such orthodontic or dental care
to third party payers and/or health practitioners. I authorize and request my insurance company to pay directly to the orthodontist insurance
benefits otherwise payable to me. I understand that my orthodontic insurance carrier may pay less than the actual bill for services. I agree to
be responsible for payment of all services rendered on my behalf or my dependents. I authorize that Dr. Daryl Yorek and staff of his practice
to provide orthodontic treatment to the patient listed on this form.
X__________________________________________________________
Date______________________________
SIGNATURE OF PATIENT (OR PARENT/GUARDIAN IF MINOR)
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