Dr. Shab Krish DDS, MS

1005 Long Prairie Road, Suite 300

Flower Mound, TX 75022

972-538-3777

TMJ & Sleep Therapy Centre of North Texas

Non-Surgical Therapies for Craniofacial Pain, TMJ Disorder & Sleep Disordered Breathing

INSTRUCTIONS FOR YOUR APPOINTMENT

The following instructions were designed just for you to make you comfortable during appointment.

MEDICATIONS: Please do not take any pain medications before your appointment to insure accurate testing for exam.

CLOTHING / MAKEUP: We will be taking diagnostic pictures and request that you wear short sleeved shirts and no collar. Long hair should be over ears and pulled back off neck and shoulders with nonmetal clips or bands. Jewelry and piercings will need to be removed from the neck and ears if at all possible. Please no heavy perfume or cologne. Ladies no lipstick or heavy makeup.

If you have any questions or concerns, please ask or call the office at. We are here to help.

NOTICE OF PRIVACY PRACTICES

Protecting Your Confidential Health Information is Important to Us

This notice describes how health information about you my be used and diselosed and how you can get access to this information.

Please review it carefully.

We want you to know about the policies and procedures which we developed to make sure your health information will not be shared with anyone who does not require it.

Our office is subject to State and Federal law regarding the confidentiality of your health information and in keeping with these laws, we want you to understand our procedures and your rights as our valuable patient.

We will use and communicate your HEALTH INFORMATION only for the purposes of providing your treatment, obtaining payment and conducting health care operations. Your health information will not be used for other purposes unless we have asked for and been voluntarily given your written permission.

HOW YOUR HEALTH INFORMATION MAY BE USED

To Provide Treatment

We will use your HEALTH INFORMATION within our office to provide you with the best care possible. This may include administrative and clinical office procedures designed to optimize scheduling and coordination of care between hygienist, dental assistant, dentist, and business office staff. In addition,we may share your health information with physicians, referring dentists, clinical and dental laboratories, pharmacies or other health care personnel providing treatment.

To Obtain Payment

We may include your health information with an invoice used to collect payment for treatment you receive in our office. We may do this with insurance forms filed for you in the mail or sent electronically. We will be sure to only work with companies with a similar commitment to the security of your health information.

To Conduct Health Care Operations

Your health information may be used during performance evaluations of our staff. Some of our best teaching opportunities use clinical situations, experienced by patients receiving care at our office. As a result, health information may be included in training programs for students, interns, associates, and business and clinical employees. It is also possible that health information will be disclosed during audits by insurance companies or government appointed agencies as part of their quality assurance and compliance reviews. Your health information may be reviewed during the routine processes of certification, licensing or credentialing activities.

In Patient Reminders

Because regular care is very important in your treatment, we will remind you of a scheduled appointment or that it is time for you to contact us and make an appointment. Additionally, we may contact you to follow up on your care and inform you of treatment options or services that may be of interest to you. These communications are an important part of our philosophy of partnering with our patients to ensure they receive the best quality care.

Abuse or Neglect

We will notify government authorities if we believe a patient is the victim of abuse, neglect or domestic violence. We will make this disclosure only when we are compelled by our ethical judgment, when we believe we are specifically required or authorized by law or with the patient's agreement.

Public Health and National Security

We may be required to disclose Federal officials or military authorities' health information necessary to complete an investigation related to public health or national security. Health information could be important when the government believes that the public safety could benefit when the information could lead to the control or prevention of an epidemic or the understanding of new side effects of a drug treatment or medial device.

For Law Enforcement

As permitted or required by State or Federal law, we may disclose your health information to a law enforcement official for certain law enforcement purposes, including, under certain limited circumstances, if you are a victim of a crime or in order to report a crime.

Family, Friends and Caregivers

We may share your health information with those you tell us will be helping you with your treatment, medications or payments. We will be sure to ask your pennission first. In the case of an emergency, where you are unable to tell us what you want we will use our very best judgment when sharing your health information only when it will be important to those participating in providing care.

Authorization to Use or Disclose Health Information

Other than is stated above or where Federal, State or Local law requires us, we will not disclose your health information other than with your written authorization. You may revoke that authorization in writing at any time.

Patient Rights

This new law is careful to describe that you have the following rights related to your health information.

Restrictions

You have the right to request restrictions on certain uses and disclosures or your health information. Our office will make every effort to honor reasonable restriction preferences from our patients.

Confidential Communications

You have the right to request that we communicate with you in a certain way. You may request that we only communicate your health information privately with no other family members present or through mailed communications that are sealed. We will make every effort to honor your reasonable requests for confidential communications.

Inspect and Copy Your Health Information

You have the right to read, review, and copy your health information, including your complete chart, x-rays and billing records. If you would like a copy of your health information, please let us know. We may need to charge you a reasonable fee to duplicate and assemble your copy.

Amend Your Health Information

You have the right to ask us to update or modify your record if you believe your health information records are incorrect or incomplete. We will be happy to accommodate you as long as our office maintains this information. In order to standardize our process, please provide us with your request in writing and describe your reason for the change.

Your request may be denied if the health information record in question was not created by our office, is not part of our records or if the records containing your health information are determined to be accurate and complete.

Documentation of Health Information

You have the right to ask us for a description of how and where your health information was used by our office for any reason other than treatment, payment or health operations. Our documentation procedures will enable us to provide information on health information usage from April 14, 2003 and forward. Please let us know in writing the time period for which you are interested. Thank you for limiting your request to no more than six years at a time. We may need to charge you a reasonable fee for your request.

Request a Paper Copy of this Notice

You have the right to obtain a copy of this Notice of Privacy Practices directly from our office at any time. Stop by or give us a call and we will mail a copy to you.

We are required by law to maintain the privacy of your health information and to provide to you and your representative this Notice of our Privacy Practices. We are required to practice the policies and procedures described in this notice but we do reserve the right to change the terms of our Notice. If we change our privacy practices we will be sure all of our patients receive a copy of the revised Notice.

You have the right to express complaints to us or to the Secretary of Health and Human Services if you believe your privacy rights have been compromised. We encourage you to express any concerns you may have regarding the privacy of your information. Please let us know of your concerns or complaints in writing.

Private Patient Agreement

I am aware that TMJ & Sleep Therapy Centre of North Texas is not contracted with my insurance company. I am requesting to be seen as a private patient and completely understand I will be responsible for full fees on a private pay basis. I also understand that if Medicare is my primary insurance that I cannot file any claims with them as Dr. Krish is not a Medicare provider. I agree to pay for treatment services at TMJ & Sleep Therapy Centre of North Texas at the fee schedule based on their private practice charges.

Signature:

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Date:

HIPPA- Privacy Practices:

Acknowledgement of receipt of Notice of Privacy Practices:

I have received a copy of this office's Notice of Privacy Practices

Signature:

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Date:

Medical Insurance Information

Our office is not a network provider for any Medica/Insurance or Medicare. All fees are due on the day services are rendered. If you need authorization to see an out of network provider, it is your responsibility to call and get the prior authorization. We will be happy to assist you in filing your claims and all reimbursement by your insurance company will be assigned directly back to you. When getting authorization,ask your insurance company for a gap exception.

Insurance Provider
Phone #
Claims Mailing Address:
Policy Holder:
Employer:
SS#:
ID#:
DOB:
Group#:
Insurance Plan or Program Name:
Patient Status:
Patient Relationship to Policy Holder:

Since we are not a Medicare provider, claims cannot be filed with Medicare for treatment.

Possible codes that could be a part of your treatment:

99204 New Patient Comprehensive Evaluation
76102 Bilateral Sagittal TMJ Tomogram
70355 Panoramic
70250 Submental Vertex
E1399 or D7880 (for some insurance companies) Mandibular Orthopedic Repositioning TMJ Appliance
E0486 Lab Processed OSA Appliance

Comprehensive Health Questionnaire

Patient Information

Patient Name:
Phone:
Age:
DOB:
Height:
Weight:
Referred by:
Address and/or Phone Number of Healthcare Provider:
Patient Address:
City:
State:
Zip:
Home Phone:
Alternate Contact Number:
Email:
Type of Employment:
Place of Employment:
Responsible Party (if different than patient):
Patient Address:
City:
State:
Zip:
Family Physician:
Phone Number:
Family Dentist:
Phone Number:
What is your chief concern and reason for this visit:
What are the results you are seeking from treatment:

Dear Patient,

Please read each question and be as thorough/ detailed as possible. Answer every question even if you don't think it applies to you. On the second page of the Patient Health Questionnaire please mark all of your chief complaints and if they are recent or chronic. Once you have marked your chief complaints then go back through them and put them in order from #1 to however many you have, with #1 being your biggest complaint and so on.

Example:

Do you currently experience any of the following symptoms?

Headache
Earpain
Jaw Pain
Kicking or jerking leg repeatedly
Swelling in ankles or feet
Morning Hoarseness

Do you currently experience any of the following symptoms?

Please number your chief complaints from 1 to however many you have

R - Recent C - Chronic

Headache (inside your head)
Headache (outside your head)
Jaw Pain
Chewing Pain
Face Pain
Eye Pain
Throat Pain
Neck Pain
Shoulder Pain
Back Pain
Dyskinesia
Difficulty Opening Mouth
Difficulty Closing Mouth
Noises in Jaw Joints
Ear Stuffiness
Dizziness
Ringing in Ears (Tinnitis)
Vision Problems
Muscle Spasm
Sinus Congestion
Kicking or jerking leg repeatedly
Swelling in ankles or feet
Numbness (Localized)
Nerve Pain
Dental Changes
Teeth Spacing
Teeth Sensitivity
Changes with your Bite
Morning Hoarseness
Dry Mouth Upon Waking
Fatigue
Difficulty Falling Asleep
Tossing and Turning Frequently
Repeated Awakening
Feeling Un-refreshed in the Morning
Morning Headaches
Nighttime Urination
Night Sweats
Vivid Dreams
Sore Jaw Upon Waking
Significant Daytime Drowsiness
Affect Sleep of Others
Short of Breath when Waking
Told “I stop breathing” During Sleep
Night-Time Choking Spells
Unable to Tolerate C-Pap
Tooth Grinding
Teeth Crowding
Frequent Heavy Snoring
Acid Indigestion
Any Other Symptoms not listed above

Patient/Parent Signature:

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Date:

Sleep Conditions

Please select the yes or no answers based on your average sleep experience and/or what a sleep partner has told you

Sleep Position?
Bed Partner?
Is it easy to fall asleep?
Do you wake often during the night?
Do you feel rested upon waking?
Stopped breathing during sleep?
Have you ever had a Sleep Study?
Sleep Location?
Average hours of sleep per night?
Average hours of sleep per day?
Cough, gasps or snorts on waking?
Observed pauses in breath?
Date:
Result:
Previous Positive Airway Pressure Devices Used?
Do you currently use a PAP Device?
If yes, what?
Previous Oral Appliance?
If yes, what?

Allergic Reactions

Please check any and all medications or substance that have caused an allergic reaction

Other

Current Medications

Please list all medications and supplements (over-the-counter and prescription) you are taking and the reason you take them

Medication

Dosage

Reason for Taking

Previous Treatment, Medications and Other Therapies Attempted For The Condition We Are Evaluating

Treatment/ Med/ Therapy

Doctor/ Provider

Approx. Date of Tx

Helpful (y/n)

Health And Medical History

Are you currently pregnant?
Do you drink 4 or more cups of coffee per day?
Do you smoke tobacco?
Do you consume alcohol or take sedatives?
Do you have trouble breathing through your nose?
Have you had prior orthodontic treatments?
Have you sustained injury to:

Surgical History

Have you had any of the following:

General Anesthesia
Orthognathic Surgery
Adenoids Removed
Oral Surgery
Tonsils Removed
Removal of Third Molar
Jaw Joint Surgery

Other types of surgery:

Patient/Parent Signature:

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Date:

Additional Health And Medical History

Do you have or have you experienced any of the following

Anemia
Anxiety
Asthma
Bleeding Easily
Birth Defects
Bruising Easily
Cancer of
Chemo
Chronic Fatigue
Cold Hands and Feet
COPD
Depression
Diabetes
Difficulty Concentrating
Difficulty Breathing at Night
Dizziness
Emphysema
Epilepsy
Excessive Thirst
Fainting
Fibromyalgia
Fluid Retention
Frequent Colds/Flu
Frequent Cough
Frequent Ear Infections
Frequent Sore Throat
Awakening from Sleep
Gastroesophogeal Reflux
Glaucoma
Hay Fever
Hearing Impairment
Heart Attack
Heart Disease
Heart Murmur
Heart Pacemaker
Heart Palpitations
Heart Valve Replacement
Hemophilia
Hepatitis
High Blood Pressure
History of Substance Abuse
Huntington’s Disease
Hypoglycemia
Insomnia
Intestinal Disorder
Irregular Heartbeat
Kidney Disease
Leukemia
Liver Disease
Low Blood Pressure
Meniere’s Disease
Memory Loss
Migraines
Mitral Valve Prolaps
Multiple Sclerosis
Muscle Aches
Muscle Fatigue
Muscle Spasms
Muscular Dystrophy
Neuralgia
Nervous system Disorder
Osteoarthritis
Osteoporosis
Ovarian Cyst
Parkinson’s Disease
Poor Circulation
Psychiatric Care
Radiation
Recent Weight Gain
Recent Weight Loss
Rheumatic Fever
Rheumatoid Arthritis
Scarlet Fever
Shortness of Breath
Skin Disorder
Sinus Problems
Slow Healing Sores
Speech Difficulties
Stroke
Swollen or Painful Joints
Thyroid Disease
Tired Muscles
Tuberculosis
Urinary Tract Disorder

Patient/Parent Signature:

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Date:

Additional Symptoms

Head Pain

Location

(L = Left R = Right B = Bilateral)

Temple Area
Back of Head
Forehead
Top of Head
All of Head

Recent



Chronic

(over 6mo)

Severity

Mild Mod Severe

Duration

Hrs Days Wks

Frequency

Occ Freq Constant

Jaw Pain

Jaw pain with opening
Jaw pain with chewing
Jaw pain at rest

Jaw Joint Sound

Jaw sounds with opening
Jaw sounds with chewing

Jaw Locking

Jaw locks closed
Jaw locks open

Jaw Joint Symptoms

Teeth clenching
Teeth grinding

Eye Related Conditions

Blurred vision
Double vision
Eye pain
Pain or pressure behind the eyes
Extreme sensitivity to light
Wear of glasses or contacts

Ear Related Conditions

Buzzing in ears
Ear Congestion
Ear pain
Hearing Loss
Itchiness/ stuffiness
Pain behind the ear
Pain in front of ear
Recurrent ear infections
Ringing in the ear (tinnitus)

Throat Related Conditions

Chronic sore throat
Difficulty Swallowing
Swollen glands
Thyroid enlargement
Tightness in throat
Feeling of foreign object in throat

Neck related Conditions

Limited movement
Neck pain
Numbness in hands/ fingers
Swelling in neck

Shoulder Conditions

Pain in Shoulder
Stiffness in Shoulder
Tingling in fingers/hands

Back Conditions

Low Back Pain
Middle Back Pain
Upper Back Pain
Scoliosis
Sciatica

Mouth/Nose Conditions

Chronis Sinusitis
Dry Mouth
Frequent Snoring
Broken Teeth
Biting Cheeks
Burning Tongue

Patient/Parent Signature:

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Date:

History of Symptoms

On what date, or approximate date, did the condition you are seeking treatment for occur?
Are any of the conditions listed or was your chief complaint caused by a motor vehicle accident?
If yes, what conditions:
Date of accident:
Does any family member have a sleep breathing disorder?
If yes, explain:

Adult - Complete this section

1. DAYTIME SLEEPINESS EVLAUATION - EPWORTH SLEEPINESS SCALE

For the following situations, answer with one of the following numbers:

0 - would never doze 1 - slight chance of dozing 2 - moderate chance of dozing 3 - high chance of dozing

Situation

Sitting and reading
Watching Television
Sitting, inactive public place
As a passenger in a car for an hour without a break

Situation

Sitting and talking to someone
Sitting quietly after a lunch (no alcohol)
In a car, while stopped for a few minutes in traffic
Lying down to rest in the afternoon when circumstances permit
TOTAL SCORE

2. NIGHTTIME SLEEPINESS EVALUATION

1. Snoring

a) Do you snore on most nights (>3 nights per week)?

Yes(2)         No(0)

b) Is your snoring loud? Can it be heard through a door or wall?

Yes(2)         No(0)

2. Has it ever been reported to you that you stop breathing or gasp during sleep?

Never(0)       Occasionally(3)       Frequently(5)

3. What is your collar size?

Male:       Less than 17 inches (0)        More than 17 inches (5)
Female:       Less than 16 inches (0)        More than 16 inches (5)

4. Do you occasionally fall asleep during the day when:

a) You are busy or active

Yes(2)         No(0)

b) You are driving or stopped at a light?

Yes(2)         No(0)

5. Have you had or are you being treated for high blood pressure?

a) You are busy or active

Yes(2)         No(0)
TOTAL

I authorize the release of all examination findings and diagnosis, report and treatment plans, etc., to any referring or treating health care provider. I additionally authorize the release of any medical information to insurance companies, third party billing companies, or for legal documentation to process claims. I understand that I am responsible for all charges incurred for my treatment regardless of insurance coverage.

Patient/Parent Signature:

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Date:

3. Child - Complete this section

BEARS SLEEP SCREENING ALGORITHM

The “BEARS” instrument is divided into five major sleep domains, providing a comprehensive screen for the major sleep disorders affecting children in the 2- to 18-year old range. Each sleep domain has a set of age-appropriate “trigger questions” for use in the clinical interview

B = bedtime problems

E = excessive daytime sleepiness

A = awakenings during the night

R = regularity and duration of sleep

S = snoring

Symptom Age Toddler/Preschool (2-5 years) Age School Age (6-12 years) Age Adolescent (13-18 years)
1. Bedtime Problems
Does your child have any problems going to bed?
Does your child have any problems at bedtime? (P)
Do you have any problems going to bed? (C)
Do you have any problems falling asleep at bedtime?(C)
2. Excessive Daytime Sleepiness
Does your child seem overtired or sleepy a lot during the day?
Does your child have difficulty waking in the morning, seem sleepy during the day or take naps? (P)
Do you feel tired a lot? (C)
Do you feel sleepy a lot during the day?
In School?
While Driving? (C)
3. Awakenings during the night
Does your child wake up a lot at night? (P)
Does your child seem to wake up a lot at night?
Any sleepwalking or nightmares?
Do you wake up a lot at night?
Have trouble getting back to sleep? (C)
Do you wake up a lot at night?
Have trouble getting back to sleep? (C)
4. Regularity and duration of sleep
Does your child have a regular bedtime and wake time?
What are they?
What time does your child go to bed and get up on school days?
Weekends?
Do you think he/she is getting enough sleep? (P)
What time do you usually go to bed on school nights?
Weekends?
How much sleep do you usually get?(C)
5. Snoring
Does your child snore a lot or have difficult breathing at night?
Does your child have loud or nightly snoring or any breathing difficulties at night? (P)
Does your teenager snore loudly or nightly? (P)

(P) Parent-directed question

(C) Child-directed question

Patient/Parent Signature:

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Date:

L = Left    R = Right

Front Area
Back Area
Right
Left

Indicate Areas of Pain

Following the Pain Scale:

AUTHORIZATION TO RELEASE INFORMATION TO THE BELOW LISTED REFERRING AND TREATING HEALTH CARE PROFESSIONALS

Name

Location/ Phone Number

I authorize the release of communications regarding my treatment with Shab R. Krish DDS, MS including a full report of examination findings, diagnosis, treatment plan, and progress reports to the providers/individuals listed above.

Signature

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Date: