WWEELLCCOOMMEE!! The benefits of a happy, healthy smile are immeasurable! Our goal is to help you reach and maintain maximum oral health.

Please fill out these forms completely. The better we communicate, the better we can care for you. TODAY’S DATE:

NAME:

last first middle Mr. Mrs. Ms. Dr.

BIRTHDATE: /__ / AGE: SSN:

HOME ADDRESS:

city state zip ��Single ��Married �� Divorced �� Widowed �� Separated

Home #: Cell #:

Work #: Ext # Email _

Dental Insurance Medical Insurance

Person financially responsible:

IF DIFFERENT FROM PATIENT (relationship to patient)

Where & when are best times to reach you? _

Who may we THANK for referring you? _

Previous Dentist:

Primary Care Physician

Referring Physician

Sleep Physician

Last dental visit:

Phone :

Phone : _

Phone :

Other Physicians you are under the care of:_

DENTAL HISTORY / INFORMATION

Why have you come to the dentist today?

Do you have or have you experienced any of the following: (please check)

◻ Serious / difficult problem associated with any dental work ◻ Pain or discomfort in your jaw joints (TMJ) ◻ Face sore or feel tight in the morning ◻ Jaw sometimes difficult to open or close, clicking or popping ◻ Clenching or grinding your teeth ◻ Teeth sensitive to cold, heat, pressure or sweets ◻ Unpleasant taste in your mouth or persistent bad breath ◻ Teeth loose or shifting ◻ Bleeding gums

How would you evaluate your dental health: ��Excellent ��Good ��Fair ��Poor Do you have any skin allergies? (This would include reactions to wearing jewelry) Yes No

SOCIAL HISTORY Employer: Occupation: Children Yes/No If yes, how many children? Are you currently under unusual stress? Y/N Recent change in lifestyle? Y/N Do you exercise regularly? Y/N

What are their ages?

Do you chew tobacco? Y/N Do you smoke Y/N If so, # per day/week

Alcohol consumption-None/Social Drinker/Occasional/Daily MEDICAL HISTORY

Your current physical health is: ��Excellent ��Good ��Fair � Poor Are you currently under the care of a physician? ��No ��Yes If yes, please explain: Are you taking any prescriptions / over-the-counter drugs? Medicine Dose/Times per day For 1 2 3 4 5 6

For Women only: Are you taking birth control pill? ��No � Yes Are you pregnant? ��No � Yes Are you nursing? ��No ��Yes

Have you ever had any of the following disease or medical problem? (PLEASE CHECK)

�����

Heart attack / stroke Mitral Valve Prolapse Heart murmur

Please list any serious medical condition(s) that you have ever had:

���

Rheumatic fever Congenital heart defect

���

Heart surgery / pacemaker Shingles

�������������

Cancer / chemotherapy Kidney problems Artificial bones / joints Sinus problems High / Low blood pressure (circle) Fever blisters Severe / frequent headaches

Are you allergic to any of the following drugs? (Please check)

Penicillin Tetracycline ���������

Psychiatric problems Epilepsy / Seizures / Fainting spells Diabetes Tuberculosis (TB) Drug / Alcohol abuse

Aspirin Dental anesthetics Erythromycin Codeine Latex Other

� Venereal disease Please list any other drugs that you are allergic to: ���

Hemophilia / Abnormal bleeding HIV+ / AIDS

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Anemia / Radiation treatment Asthma / hay fever

���

Difficulty breathing Hepatitis

� Blood transfusion E M E R G E N C Y C O N TACT : ���������

Emphysema Glaucoma Ulcers / colitis Thyroid disease Nervous disorder

Name:

Phone #: ____________________________________________ _________________________________________________________

THANK YOU! For filling out these forms completely. It will enable us to help you more effectively. If you have any questions at any time, please ask us. We are happy to help.

I understand that I am responsible for the payment of all charges for services rendered, regardless of insurance, and that any amount

remaining unpaid more than 60 days after the services were rendered will accrue interest at the rate of 18% per annum. Should the account be turned over to an attorney, I agree to pay 33.3% attorney’s fees and all court costs.

I understand that if I cancel an appointment without giving at least 48 hours prior notice, I may be charged $150 per each hour

scheduled. (NOTE: Leaving a message on our answering machine does not constitute proper notice to the practice.)

SIGNATURE: PATIENT or Patient’s Parent/or Child Guardian

DATE:

Smile Assessment Form

Please consider each statement carefully and circle YES or NO. The Doctor and members of the dental team will discuss your responses with you in confidence. Name: ____________________________ Date: ________________ 1 I am concerned about the appearance of my teeth or smile. YES NO

2 I am concerned about the whiteness/lack of whiteness of one or more of my teeth. YES NO

3 I am concerned about the position or angle of one or more of my teeth. YES NO

4 I am concerned about the shape of one or more of my teeth. YES NO

5 In social situations, my teeth or smile sometimes embarrasses me. YES NO

6 There are some things about my upper front teeth I would like to change. YES NO

7 There are things about my lower front teeth that I would like to change. YES NO

8 I have old fillings or previous dental treatment that is no longer satisfactory to me. YES NO

9 I am missing one or more of my teeth. YES NO

10 I am interested in learning more about: Cosmetic dentistry Sedation Dentistry Invisalign�

Whitening

YES YES YES YES

NO NO NO NO

Please use the space below to indicate any other problems, concerns, or questions you may have. We will make every effort to listen attentively to your concerns so that we may present you with the best possible treatment options. Thank you.

HHCCJJ H . C h a r l e s J e l i n e k , J r . , D . D . S

8505 Arlington Blvd., Suite 260. Fairfax, VA 22031-4621 Phone (703) 560-8700 Fax (703) 560-1745

www.NorthernVirginiaDental.com

The STOP-BANG Questionnaire

A Tool to Screen Patients for Obstructive Sleep Apnea (OSA)

1. Snore. Have you been told you snore? Do you snore loudly (louder than talking or loud

enough to be heard through closed doors)? �Yes � No

2. Tired. Do you often feel tired, fatigued, or sleepy during daytime?

�Yes �No 3. Obstruction. Do you know if you have stopped breathing or has anyone observed you stop

breathing while you are asleep? �Yes �No

4. Pressure. Do you have or are you being treated for high blood pressure?

�Yes �No 5. Body Mass Index (BMI). IS you BMI more than 30 (use the formula to calculate your BMI)?

�Yes �No BMI Formula: (your weight in pounds X 703) BMI = (your height in inches X your height in inches) 6. Age. Are you 50 years or older?

�Yes �No 7. Neck. Is your neck circumference greater than 17 inches for a male or 15 inches for a

female? �Yes � No

8. Gender. Are you a male?

�Yes �No Scoring: Answering "yes" to three of more of the 8 questions indicates that you are High Risk for OSA. Answering “yes” to less than three questions indicates that you are Low Risk for OSA. If you scored in the High Risk for OSA category, a sleep study or an evaluation by a sleep specialist may be warranted.

HHCCJJ H . C h a r l e s J e l i n e k , J r . , D . D . S

8505 Arlington Blvd., Suite 260. Fairfax, VA 22031-4621 Phone (703) 560-8700 Fax (703) 560-1745

www.NorthernVirginiaDental.com

Initial Patient Sleep Screening Form v. 1.0

___________________________________

Patient Name (PRINT) 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 Sitting and reading ………………………………………………………….. 0 1 2 3 Watching television ………………………………………………………… 0 1 2 3 Sitting in a public place ……………………………………………………... 0 1 2 3 As a passenger in a car for one hour ………………………………………... 0 1 2 3 Driving a car stopped for a few minutes in traffic ………………………….. 0 1 2 3 Sitting & talking to someone ……………………………………………….. 0 1 2 3 Sitting down quietly after lunch without alcohol …………………………… 0 1 2 3 Lying down to rest in the afternoon ………………………………………… 0 1 2 3 Total Score: ______ Section 2: Patient Evaluation Fill in the blanks, circle one yes or no response for each question

No (0) Yes (1) BMI (See Attached Chart): ______ Is it greater than or equal to 30? 0 1 Neck Circumference ______ Is it >17” (Men) or >15”(Women)? 0 1 Have you gained at least 15 pounds in the past 6 months? 0 1 Total Score: ______ Section 3: Subjective Sleep Evaluation Please circle one yes or no response for each question

No (0) Yes (1) Do you snore? .......................................................................................................... ............ 0 1 You, or your spouse, would consider your snoring louder than a person talking………… 0 1 Your snoring occurs almost every night………………………………………………….. 0 1 Your snoring is bothersome to your bed partner…………………………………............. 0 1 Do you feel that in some way your sleep is not refreshing or restful? ................................ 0 1 Do you wake up at night or in the mornings with headaches? ............................................ 0 1 Do you experience fatigue during the day and have difficulty staying awake? .................. 0 1 Do you have trouble remembering things or paying attention during the day? .................. 0 1 Do you have high blood pressure? ...................................................................................... 0 1 Total Score: ______ Section 4: Prior Diagnosis

No(0) Yes(1) Have you previously been diagnosed with sleep apnea? 0 1

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: ______ Notes: (Please insert any notes for the doctor regarding snoring, sleep patterns or sleep apnea that you feel may be appropriate use back of page if necessary.) Patient Signature: ___________________________________ Date: ____/____/________ OFFICE USE ONLY Advanced screening criteria, if yes to any below pt should be scheduled for advanced OSA screening.

______ ESS Score ≥ 8? _____ Pt. Eval ≥ 2? _____ Subjective Sleep Eval ≥ 3? _____ Prior OSA Diagnosis ≥ 1?

NOTICE OF PRIVACY PRACTICESTHIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND

DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

PLEASE REVIEW IT CAREFULLY. THE PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT TO US.

OUR LEGAL DUTYWe are required by applicable federal and state law to maintain the privacy of your health information. We are alsorequired to give you this Notice about our privacy practices, our legal duties, and your rights concerning your healthinformation. We must follow the privacy practices that are described in this Notice while it is in effect. This Noticetakes effect ______________, and will remain in effect until we replace it.

We reserve the right to change our privacy practices and the terms of this Notice at any time, provided suchchanges are permitted by applicable law. We reserve the right to make the changes in our privacy practices and thenew terms of our Notice effective for all health information that we maintain, including health information we creat-ed or received before we made the changes. Before we make a significant change in our privacy practices, we willchange this Notice and make the new Notice available upon request.

You may request a copy of our Notice at any time. For more information about our privacy practices, or for addition-al copies of this Notice, please contact us using the information listed at the end of this Notice.

USES AND DISCLOSURES OF HEALTH INFORMATIONWe use and disclose health information about you for treatment, payment, and healthcare operations. For example:

Treatment: We may use or disclose your health information to a physician or other healthcare provider pro-viding treatment to you.

Payment: We may use and disclose your health information to obtain payment for services we provide to you.

Healthcare Operations: We may use and disclose your health information in connection with our healthcare oper-ations. Healthcare operations include quality assessment and improvement activities, reviewing the competence orqualifications of healthcare professionals, evaluating practitioner and provider performance, conducting trainingprograms, accreditation, certification, licensing or credentialing activities.

Your Authorization: In addition to our use of your health information for treatment, payment or healthcare opera-tions, you may give us written authorization to use your health information or to disclose it to anyone for any pur-pose. If you give us an authorization, you may revoke it in writing at any time. Your revocation will not affect any useor disclosures permitted by your authorization while it was in effect. Unless you give us a written authorization, wecannot use or disclose your health information for any reason except those described in this Notice.

To Your Family and Friends: We must disclose your health information to you, as described in the PatientRights section of this Notice. We may disclose your health information to a family member, friend or other personto the extent necessary to help with your healthcare or with payment for your healthcare, but only if you agree thatwe may do so.

Persons Involved In Care: We may use or disclose health information to notify, or assist in the notification of(including identifying or locating) a family member, your personal representative or another person responsible foryour care, of your location, your general condition, or death. If you are present, then prior to use or disclosure of yourhealth information, we will provide you with an opportunity to object to such uses or disclosures. In the event of yourincapacity or emergency circumstances, we will disclose health information based on a determination using ourprofessional judgment disclosing only health information that is directly relevant to the person’s involvement in yourhealthcare. We will also use our professional judgment and our experience with common practice to make reason-able inferences of your best interest in allowing a person to pick up filled prescriptions, medical supplies, x-rays, orother similar forms of health information.

Marketing Health-Related Services: We will not use your health information for marketing communicationswithout your written authorization.

Required by Law: We may use or disclose your health information when we are required to do so by law.

Abuse or Neglect: We may disclose your health information to appropriate authorities if we reasonably believe thatyou are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes. We may dis-close your health information to the extent necessary to avert a serious threat to your health or safety or the healthor safety of others.

H. Charles Jelinek Jr. D.D.S.

11/18/2015

National Security: We may disclose to military authorities the health information of Armed Forces personnel undercertain circumstances. We may disclose to authorized federal officials health information required for lawful intelli-gence, counterintelligence, and other national security activities. We may disclose to correctional institution or lawenforcement official having lawful custody of protected health information of inmate or patient under certain circum-stances.

Appointment Reminders: We may use or disclose your health information to provide you with appointmentreminders (such as voicemail messages, postcards, or letters).

PATIENT RIGHTSAccess: You have the right to look at or get copies of your health information, with limited exceptions. You mayrequest that we provide copies in a format other than photocopies. We will use the format you request unless wecannot practicably do so. (You must make a request in writing to obtain access to your health information. You mayobtain a form to request access by using the contact information listed at the end of this Notice. We will charge youa reasonable cost-based fee for expenses such as copies and staff time. You may also request access by sending usa letter to the address at the end of this Notice. If you request copies, we will charge you $0.______ for each page,$_______ per hour for staff time to locate and copy your health information, and postage if you want the copies mailedto you. If you request an alternative format, we will charge a cost-based fee for providing your health information inthat format. If you prefer, we will prepare a summary or an explanation of your health information for a fee. Contactus using the information listed at the end of this Notice for a full explanation of our fee structure.)

Disclosure Accounting: You have the right to receive a list of instances in which we or our business associatesdisclosed your health information for purposes, other than treatment, payment, healthcare operations and certainother activities, for the last 6 years, but not before April 14, 2003. If you request this accounting more than once in a12-month period, we may charge you a reasonable, cost-based fee for responding to these additional requests.

Restriction: You have the right to request that we place additional restrictions on our use or disclosure of yourhealth information. We are not required to agree to these additional restrictions, but if we do, we will abide by ouragreement (except in an emergency).

Alternative Communication: You have the right to request that we communicate with you about your health infor-mation by alternative means or to alternative locations. (You must make your request in writing.) Your request mustspecify the alternative means or location, and provide satisfactory explanation how payments will be handled underthe alternative means or location you request.

Amendment: You have the right to request that we amend your health information. (Your request must be in writing,and it must explain why the information should be amended.) We may deny your request under certain circumstances.

Electronic Notice: If you receive this Notice on our Web site or by electronic mail (e-mail), you are entitled toreceive this Notice in written form.

QUESTIONS AND COMPLAINTSIf you want more information about our privacy practices or have questions or concerns, please contact us.

If you are concerned that we may have violated your privacy rights, or you disagree with a decision we made aboutaccess to your health information or in response to a request you made to amend or restrict the use or disclosure ofyour health information or to have us communicate with you by alternative means or at alternative locations, youmay complain to us using the contact information listed at the end of this Notice. You also may submit a writtencomplaint to the U.S. Department of Health and Human Services. We will provide you with the address to file yourcomplaint with the U.S. Department of Health and Human Services upon request.

We support your right to the privacy of your health information. We will not retaliate in any way if you choose to filea complaint with us or with the U.S. Department of Health and Human Services.

Contact Officer: _____________________________________________________________________________________

Telephone: __________________________________________Fax: ___________________________________________

E-mail:____________________________________________________________________________________________

Address: __________________________________________________________________________________________

© 2002 American Dental AssociationAll Rights ReservedReproduction and use of this form by dentists and their staff is permitted. Any other use, duplication or distribution of this form by any other party requires the priorwritten approval of the American Dental Association.This Form is educational only, does not constitute legal advice, and covers only federal, not state, law (August 14, 2002).

5010.00

Office Manager of H. Charles Jelinek Jr. D.D.S.

(703) 560-8700 (703) 560-1745

JelinekDDS@gmail.com

8505 Arlington Blvd. Ste. 260 Fairfax, VA 22031

H. CHARLES JELINEK, JR., D.D.S.

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES CONSENT FOR USE AND DISCLOSURE OF HEALTH INFORMATION

__________________________________________________________________________________________ SECTION A: PATIENT GIVING CONSENT Name: ____________________________________________________________________________________________ Address: __________________________________________________________________________________________ Telephone: ____________________________________ Email: ______________________________________________ __________________________________________________________________________________________________ SECTION B: TO THE PATIENT—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 been given a copy of our Notice of Privacy Practices to read before you decide whether to sign 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. Your copy of our Notice accompanies this Consent. We encourage you to read it carefully and completely before signing this Consent. We reserve the right to change our privacy practices as described in our Notice of Privacy 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. You may obtain a copy of our Notice of Privacy Practices, including any revisions of our Notice, at any time by contacting: Telephone: 703-560-8700 Fax: 703-560-1745 Address: 8505 Arlington Blvd. Ste. 260 Fairfax, VA 22031 Right to Revoke: You will have the right to revoke this Consent at any time by giving us written notice of your revocation submitted to the Contact 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 to continue treating you if you revoke this Consent. My protected health information for treatment, payment activities and health care operations may be released to the persons I have specified below: Name: ________________________________ Relationship: ______________________________ Telephone: ______________________________

� Health information � Financial information

Name: ________________________________ Relationship: _______________________________ Telephone: _____________________________

� Health information � Financial information

SIGNATURE 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: ____________________________________________________________________________________________________

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 � Communications barriers prohibited obtaining the acknowledgement � An emergency situation prevented us from obtaining acknowledgement � Other (Please specify):

HHCCJJ H . C h a r l e s J e l i n e k , J r . , D . D . S

8505 Arlington Blvd., Suite 260. Fairfax, VA 22031-4621 Phone (703) 560-8700 Fax (703) 560-1745

www.NorthernVirginiaDental.com

VOLUNTARY RELEASE FOR USE OF WRITTEN OR VIDEO REVIEW

H Charles Jelinek, Jr., D.D.S. may publish your testimonial as part of our effort to continue providing the best dentistry to as many patients as possible. Participating by signing this release is completely voluntary on your part. In order to do so, please read carefully and sign below:

I do hereby remise, release and forever discharge H Charles Jelinek, Jr., D.D.S. or any of its assigns, parents, affiliated companies, their licensees, persons or companies exhibiting or scheduled to exhibit the material, their advertising agencies and the officers, directors, agents, and employees of the foregoing companies of and from all rights, claims, liabilities, known or unknown, whether at law or in equity, that may hereafter at any time be made or brought by me for the purpose of enforcing any claim or cause of action arising out of the use, sale, broadcast, transfer, distribution, or other dissemination of said program, testimony and/or videotape recording herein described.

I acknowledge your ownership of recorded or written material and further agree that you may use my name and likeness for the purpose of promoting the H Charles Jelinek,Jr.,D.D.S. and/or photography. I warrant and represent that all material furnished by me is my own for which I have full authority for such purposes.

H Charles Jelinek, Jr., D.D.S.:

PRINT NAME: _____________________________________________________

SIGNATURE: ________________________________ DATE: _______________

(If a minor, parent or guardian signature)

PHONE: ( )

WITNESS: __________________________________________________________________