Welcome to Aventura Dental Arts, LLC Bienvenido a Aventura

Welcome to Aventura Dental Arts, LLC Bienvenido a Aventura

Welcome to Aventura Dental Arts, LLC
Bienvenido a Aventura Dental Arts, LLC
Patient Information / Información del Paciente
First Name / Nombre
Last Name / Apellido
Preferred Name / Nombre Preferido
Address / Dirección
City / Ciudad
State / Estado
Home Phone Number / Teléfono de Casa
Work Phone Number / Teléfono del Trabajo
Cell Phone Number / Teléfono Celular
Date of Birth / Fecha de Nacimiento
Social Security Number / Número de Seguro Social
Drivers License / Número de Licencia de Conducir
Email Address / Correo Electronico
Occupation / Ocupación
Sex: Male or Female / Sexo: Masculino / Femenino
Marital Status / Estado Civil
Zip / Código Postal
Responsible Party / Información del Responsable
(if other than the patient / si no es el paciente)
Relationship to Patient / Relación con el Paciente
First Name / Nombre
Last Name / Apellido
Address / Dirección
City / Ciudad
State / Estado
Home Phone Number / Teléfono de Casa
Work Phone Number / Teléfono del Trabajo
Cell Phone Number / Teléfono Celular
Date of Birth / Fecha de Nacimiento
Social Security Number / Número de Seguro Social
Drivers License / Número de Licencia de Conducir
Zip / Código Postal
Primary Insurance Information / Información de Seguro Primario
Name of Insured / Nombre del Asegurado
Relationship to Patient / Relación con el Paciente
Social Security Number / Número de Seguro Social
Policy Holder's Date of Birth / Fecha de Nacimiento del Titular de Póliza
Employer Name / Nombre del Empleador
Insurance Company / Empresa de Seguro
Insurance Company's Phone Number / Teléfono del Empresa de Seguro
Group or Policy Number / Número de Poliza o Grupo
Secondary Insurance Information / Información de Seguro Secundario
Name of Insured / Nombre del Asegurado
Relationship to Patient / Relación con el Paciente
Social Security Number / Número de Seguro Social
Policy Holder's Date of Birth / Fecha de Nacimiento del Titular de Póliza
Employer Name / Nombre del Empleador
Insurance Company / Empresa de Seguro
Insurance Company's Phone Number / Teléfono del Empresa de Seguro
Group or Policy Number / Número de Poliza o Grupo
Aventura Dental Arts, LLC
Medical History / Antecedentes Médicos
Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking,
could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions. / Aunque los problemas dentales se tratan principalmente en la
boca, su boca es una parte de su cuerpo. Problemas de salud que usted pueda tener, o medicaciones que usted pueda estar tomando, podrían tener una importante relación con el tratamiento
dental que usted recibirá. Gracias por contestar las siguientes preguntas.
Primary Care Physicians Name / Médico de Atención Primaria
Physician Phone Number / Teléfono del Médico
Are you under a physician's care? / ¿Se encuentra bajo cuidado médico?
Y/S
N/N
Have you ever been hospitalized or had a major operation? / ¿Alguna vez ha sido hospitalizado o ha sido sometido a una intervención quirúrgica importante?
Y/S
N/N
Have you ever had a serious head or neck injury? / ¿Ha sufrido alguna vez una lesión de cabeza o cuello grave?
Y/S
N/N
Women: Are you pregnant, trying to get pregnant or nursing? / Mujeres: ¿Está embarazada, intentando quedar embarazada o amamantando?
Y/S
N/N
Do you use controlled substances? / ¿Utiliza sustancias de consumo controlado?
Y/S
N/N
Do you use tobacco? / ¿Fuma o consume tabaco?
Y/S
N/N
Are you on a special diet? / ¿Está usted en alguna dieta especial?
Y/S
N/N
If you answered yes to any of the above questions, please explain: / Si respondió sí a cualquiera de las preguntas anteriores, por favor explique:
Please check any medications and/or supplements taken in the past 12 months: / Marque los medicamentos y/o los sulpementos que haya tomado en los ultimos 12 meses:
Antibiotics or Sulfa drugs / Antibióticos o fármacos con sulfa
Nitroglycerine / Nitroglicerina
Tranquilizer / Tranquilizantes
Anticoagulants (e.g. Coumadin, blood thinners) / Anticoagulantes (por ej. Coumadin)
Aspirin (daily) / Aspirina (diariamente)
Contraceptives / Pildoras anticonceptivas
Insulin or diabetes medication / Insulina o medicamentos para la diabetes
Herbal supplements / Suplementos a base de hierbas
Bisphosphonates (used to treat osteoporosis, such as Fosamax , Boniva, Actonel and
Zometa) / Bifosfonatos (usados para tratar la osteoporosis, como Fosamax, Boniva,
Actonel y Zometa)
High blood pressure medicine / Medicina para la presión arterial elevada
Phen-Fen or Redux / Phen-Fen o Redux
Heart medications / Medicamentos para el corazón
Aredia / Aredia
List all medication/supplements you are currently taking: / Mencione todos los medicamentos/suplementos que esté tomando actualmente:
Are you allergic or do you react adversely to any of the following? / ¿Es usted alérgico o sufre reacciones adversas a alguno de los siguientes elementos?
Aspirin / Aspirina
Tetracycline / Tetraciclina
Penicillin or other antibiotics / Penicilina u otros antibióticos
Acrylic / Acrílico
Sulfa drugs / Fármacos con sulfa
Barbiturates, sedatives or sleeping pills / Barbitúricos, sedantes u otras píldoras para dormir
Latex / Látex
Codeine / Codeína
Metal / Metal
Other: / Otros:
Local Anesthetics (Novacaine-like medication) / Anestésicos locales (medicamento parecido a
la Novacaina)
Please list other allergies: / Por favor mencione otras alergias:
Please check any conditions that you currently or previously have had: / Marque las condiciones que tenga actualmente o que haya tenido anteriormente:
AIDS/HIV Positive / SIDA/VIH positivo
Excessive Thirst / Sed excesiva
Parathyroid Disease / Enfermedad paratiroidea
Alzheimer's Disease / Enfermedad de Alzheimer
Fainting Spells/Dizziness / Desmayos/mareos
Parkinson's Disease / Enfermedad de Parkinson
Anaphylaxis / Anafilaxis
Frequent Cough / Tos frecuente
Psychiatric Care / Atención psiquiátrica
Anemia / Anemia
Frequent Diarrhea / Diarrea frecuente
Radiation Treatments / Radioterapia
Angina / Angina
Frequent Headaches / Dolores de cabeza frecuentes
Recent Weight Loss / Pérdida de peso reciente
Arthritis/Gout / Artritis/Gota
Genital Herpes / Herpes genital
Renal Dialysis / Diálisis renal
Artificial Heart Valve* / Válvula cardíaca artificial*
Glaucoma / Glaucoma
Rheumatic Fever / Fiebre reumática
Artificial Joint* / Articulación artificial*
Hay Fever / Fiebre del heno
Rheumatism / Reumatismo
Asthma / Asma
Heart Attack/Failure / Insuficiencia/ataque cardíaco
Scarlet Fever / Escarlatina
Blood Disease / Enfermedad sanguínea
Heart Murmur* / Soplo cardíaco*
Shingles / Culebrilla
Blood Transfusion / Transfusión de sangre
Heart Pace Maker* / Marcapasos cardíaco*
Sickle Cell Disease / Células falciformes
Breathing Problem / Problemas respiratorios
Heart Trouble/Disease / Problemo cardíaco
Sinus Trouble / Problemas en los senos paranasales
Bruise Easily / Formación de moretones
Hemophilia / Hemofilia
Spina Bifida / Espina bífida
Bulemia or Anorexia / Bulimia o Anorexia
Hepatitis A / Hepatitis A
Cancer / Cáncer
Hepatitis B or C / Hepatitis B o C
py / Quimioterapia
p
Chemotherapy
p / Herpes
p
Herpes
Stroke / Accidente cerebrovascular
Chest Pains / Dolores en el pecho
High Blood Pressure / Presión arterial elevada
Swelling of Limbs / Hinchazón de las extremidades
Cold Sores/Fever Blisters / Aftas/ampollas
Hives or Rash / Erupciones
Thyroid Disease / Enfermedad de la tiroides
Congenital Heart Disorder / Trastorno cardíaco congénito
Hypoglycemia / Hipoglucemia
Tonsillitis / Amigdalitis
Convulsions / Convulsiones
Irregular Hearbeat / Frecuencia cardíaca irregular
Tuberculosis / Tuberculosis
Cortisone Medicine / Medicación con cortisona
Kidney Problems / Problemas renales
Tumors or Growths / Tumores o crecimientos
Diabetes / Diabetes
Leukemia / Leucemia
Ulcers / Úlceras
Drug Addiction / Drogadicción
Liver Disease / Enfermedad hepática
Venereal Disease / Enfermedad venérea
Easily Winded / Se agita fácilmente
Low Blood Pressure / Presión arterial baja
Yellow Jaundice / Ictericia
Emphysema / Enfisema
Lung Disease / Enfermedad pulmonar
None / Ninguno
Endocarditis / Endocarditis
Mitral Valve Prolapse* / Prolapso de válvula mitral*
Other / Otro
Epilepsy or Seizures / Epilepsia o convulsiones
Osteoporosis / Osteoporosis
Excessive Bleeding / Hemorragia excesiva
Pain in Jaw Joints / Dolor en las articulaciones mandibulares
List any major illness not listed above: / Mencione cualquier enfermedad importante que no se haya mencionado anteriormente:
Stomach/Intestinal Disease / Enfermedades
estomacales/intestinales
* Condition may require medication / * Estas condiciones
pueden requerir medicación
Aventura Dental Arts, LLC
Dental Health / Salud Dental
Emergency Contact Name / Nombre del Contacto de Emergencia
Phone Number / Teléfono
Previous Dentist Name / Nombre del Dentista Anterior
Previous Dentist's Number / Teléfono del Dentista Anterior
Who may we thank for recommending you to our office? / ¿Quién lo refirió?
Date of Last Cleaning / Fecha de Última Limpieza
How do you feel about the condition of your teeth? / ¿Cuál es la condicion de su salud dental?
Do you like the appearance of your smile? / ¿Está usted conforme con la apariencia de su sonrisa?
Do you like the color of your teeth? / ¿Le gusta el color de sus dientes?
How often do you floss your teeth? / ¿Cuán a menudo usted usa el hilo dental?
How often do you brush your teeth? / ¿Cuán a menudo usted se cepilla sus dientes?
What texture toothbrush do you use? (Hard, Medium, Soft or Extra Soft) / ¿Qué tipo de cepillo dental usa? (Duro, Suave o Extra Suave)?
Do you drink tea, coffee, red wine or dark soft drinks / ¿Toma usted té , café, vino tinto, o sodas oscuras?
Do you have or have you ever had any of the following: / Tienes o has tenido algunos de los siguientes:
Dental Concerns / Problemas dentales
Persistent Cavities / Caries recurrente
Cracked Teeth / Dientes fracturados
Loose or broken fillings / Empastes sueltos o rotos
Missing Teeth / Le faltan dientes
Teeth with extensive wear / Dientes desgastados
Bleeding gums when brushing or flossing / Sangramiento en las encías cuando se cepilla o
se pasa el hilo dental
Pain or difficulty chewing, talking or yawning / Dolor o dificultad cuando mastica,
habla o bosteza
Receeding gums / Recesión en sus encías
Tender or swollen gums / Encías inflamadas o sensibles
Uncomfortable or unusual bite / Mordida incomoda
Noises in the jaw joints / Ruidos en las articulaciones de las mandíbulas
Stuck, locked or disjointed jaw / Mandíbula atascada o dislocada
Temporomandibular disorder / Trastorno Temporomandibular
Taken antibiotics before dental treatment / Toma antibióticos antes de algún tratamiento
dental
Discomfort when contact is made with hot, cold sweet or sour / Sensibilidad con las
cosas calientes, frias, dulces o amargas
Strong gag reflex / Reflejo nauseoso
Sores in your mouth / Llagas en la boca
Dental anxiety / Ansiedad dental
Excessive urination / Incontinencia urinaria
Trouble sleeping / Problemas en conciliar el sueno
Automobile accident / Accidente automovilístico
If you selected any of the above concerns, please explain: / Si usted ha seleccionado alguno de los problemas listado, por favor explique:
Other dental health issues that have yet to be addressed: / ¿Hay algún problema dental que toda vía no haya sido tratado?
SIGNATURE BLOCK TO BE SIGNED WHEN YOU ARRIVE FOR YOUR APPOINTMENT / FIRMAR AL MOMENTO DE SU LLEGADA
AUTHORIZATION AND RELEASE: / AUTORIZACIÓN Y PERMISO:
I Certify that I have read and understand the above information to the best of my knowledge. The above questions have been accurately answered. I understand that providing incorrect
information can be dangerous to my health. I agree to be reponsible for payment of all services rendered on my behalf or my dependents. In the event the account is not paid and my account
has been referred to collection, I will be responsible for all fees incurred including court costs, attorney fees and collection agency fees. I give permission for the Doctors to use x-rays,
photographs and other records of treatment in Medical lectures or publications.
Yo certifico que he leído y entiendo la informacíon. Las preguntas han sido respondidas con bastante precisión. Entiendo que al dar información incorrecta podría perjudicar mi salud. Estoy de
acuerdo de hacerme responsable por los pagos de los servicios ofrecidos para mí y mis dependientes. Si por alguna razón mi cuenta no se ha pagado y se ha referido a una agencia de
cobranzas, yo seré responsable por los gastos de corte, abogado y agencia. Doy mi autorización a los doctores que usen mis radiografías, fotos y otros documentos de tratamiento en
discursos y publicaciones.
Signature of Patient (Parent or Legal Guardian if minor): /
Firma del paciente (Padre o custodio si es menor de edad):
Signature of Dentist: / Firma de dentista:
Aventura Dental Arts, L.L.C.
CONSENT FOR USE AND DISCLOSURE OF HEALTH INFORMATION
PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY
Purpose of Consent: By signing this form, you will consent to our use and disclosure of your protected health
information to carry out treatment, payment activities, and healthcare operations.
Notice of Privacy Practices: You have the right to read our Notice of Privacy Practices before you decide whether to sigh this Consent. Our Notice provides a description of our treatment, payment activities, and healthcare operations, of the uses and disclosures we may make of your protected health information, and of other
important matters about your protected health information. A copy of Notice is available on request.
We reserve the right to change our privacy practices as described in our Notice of Provacy Practices. If we change
our privacy practices, we will issue a revised Notice of Privacy Practices, which will contain the changes. Those
changes may apply to any of your protected health information that we maintain.
In order for any personal information to be given out to any other person(s) other than the patient the following release must be filled out:
I _________________________________________________authorize Aventura Dental Arts to release my medical/dental
information whether verbally or in writing to the following person(s):
Name: Relationship:
1.______________________________________________ ________________________________
2.______________________________________________ ________________________________
3.______________________________________________ ________________________________
Right to Revoke: You will have the right to revoke this Consent at any time by giving us written notice of your
revocation to the Contact Person listed above. Please understand that revocation of this Consent will not affect
any action we took in reliance on this Consent before we received your revocation, and that we may decline to treat
you or continue treating you if you revoke consent.
I, ______________________________________________, have had full opportunity to read and consider the contents of
this Consent form and your Notice of Privacy Practices. I understand that, by signing this Consent form, I am giving
my consent to your use and disclosure of my protected health information to carry out treatment, payment activities
and health care operations.
Signature:____________________________________________________Date:________________________
If this consent is signed by a personal representative on behalf of the patient, complete the following:
Personal Representative's Name:____________________________________________________________
Relationship to Patient:____________________________________________________________________
YOU ARE ENTITLED TO A COPY OF THIS CONSENT AFTER YOU SIGN IT
*You May Refuse to Sign This Acknowledgement*
For Office Use Only
We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but
acknowledgement could not be obtained because:
( )
Individual refused to sign
( )
Communication barriers prohibited obtaining the acknowledgement
An emergency situation prevented us from obtaining acknowledgement
( )
Other (Please Specify)
( )
OSA EVALUATION FORM
Patient's Name: _________________________________________________
Date:_____________
Section 1: Epworth Sleepiness Scale
Please indicate how likely you are to doze off or fall asleep in the following situations:
(0=never, 1=slight, 2=moderate, 3=high chance of dozing)‐CIRCLE ONE RESPONSE FOR EACH QUESTION
0
1
2
Sitting and reading
Watching television
0
1
2
0
1
2
Sitting in a public place
0
1
2
As a passenger in a car for one hour
0
1
2
Driving a car stopped for a few minutes in traffic
0
1
2
Sitting and talking to someone
0
1
2
Sitting down quietly after lunch without alcohol
0
1
2
Lying down to rest in the afternoon
Total Score: _______________
3
3
3
3
3
3
3
3
Section 2: Patient Evaluation
Fill in the blanks, circle one yes or no response for each question:
BMI (See attached Chart):
________ Is it greater than or equil to 30?
Neck Circumference
________ Is it > 17" (Men) or > 15" (Women)
Have you gained at least 15 pounds in the past 6 months?
Total Score: _______________
No (0)
0
0
0
Yes (1)
1
1
1
No (0)
0
0
0
0
0
0
0
0
0
Yes (1)
1
1
1
1
1
1
1
1
1
No (0)
0
Yes (1)
1
Section 3: Subjective Sleep Evaluation
Please circle one yes or no response for each question
Do you Snore?
You or your spouse would consider your snoring louder than a person talking.
Your snoring occurs almost every night.
Your snoring is bothersome to your bed partner.
Do you feel in some way your sleep is not refreshing or restful?
Do you wake up at night or in the mornings with headaches?
Do you experience fatigue during the day and have difficulty staying awake?
Do you have trouble remembering things or paying attention during the day?
Do you have high blood pressure?
Total Score: _______________
Section 4: Prior Diagnosis
Have you previously been diagnosed with Sleep Apnea?
If Yes:
When were you diagnosed? (Approx mo/yr)
Were you put on CPAP Therapy for treatment?
Are you still using your CPAP every night?
Total Score: _______________
Note: (Please insert any notes for the doctor regarding snoring, sleep patterns or sleep apnea that you feel may
be appropriate, use the back of this page if necessary.)
Patient Signature: ________________________________________________________
Date:_____________
OFFICE USE ONLY: Advanced screening criteria, if yes to any below patient should be scheduled for advanced OSA screening
_____ ESS Score >8? ______Pt. Eval >1? ______ Subjective Sleep Eval >2? ______ Prior OSA Diagnosis >1?