Office of Keerthi Senthil DDS, MS

72027 Desert Drive, Rancho Mirage,CA 92270

(760) 340- 5107

Today’s Date: _______________

Patient Information. As required by law, our office adheres to written policies and procedures to protect the privacy of information about you that we create, receive or maintain. Your answers are for our records only and will be kept confidential subject to applicable laws. Please note that you will be asked some questions about your medical history in this questionnaire and there may be additional questions or forms concerning your health. This information is vital to allow us to provide appropriate care for you. This office does not use this information to discriminate .

Are you completing this form for another person, what is your relationship to that person?

Your Name ____________________________________ Relationship ________________________

Patient Name

Last _____________________ Middle ____________________ First ________________________

Home Phone (include area code) ______________________

Mobile Phone (include area code) _____________________

Work Phone (include area code) ______________________

Address __________________________________________________________________________

City ____________________________ State ___________________ Zip Code _________________

Email ____________________________________________________________________________

Mailing Address ___________________________________________________________________

Date of Birth __________________ Sex M F Height ____________ Weight _____________

Occupation _______________________________________________________________________

Employer Name, Address ____________________________________________________________

Marital Status: Single Married Divorced Separated

Social Security Number Emergency Contact Relationship to Patient

__________________ _______________ __________________

Their Home Phone Their Cell Phone

__________________ _______________

Please tell us how you were referred to this office:

Physician Information. Please list all the physicians whose care you are currently under

Primary Care __________________________________________ Telephone _________________

Address, City, State, Zip _____________________________________________________________

Specialist Physician _____________________________________ Telephone _________________

Address, City, State, Zip _____________________________________________________________

Medical Area of Specialty ___________________________________________________________

Insurance Information. I certify that I or my dependents have insurance with the below listed companies and assign directly to XXXXXX Dental all insurance benefits. I understand that I am financially responsible for all charges, whether or not paid by insurance. I authorize the use of my signature on all insurance submissions.

Dental Insurer Company Name Name of Insured Their Soc. Sec. #

__________________________ _____________________ ____________________

Subscriber ID Number Group ID Number

__________________________ _____________________

Medical Insurer Company Name Name of Insured Their Soc. Sec. #

__________________________ _____________________ ____________________

Subscriber ID Number Group ID Number

__________________________ _____________________

Secondary Medical Insurance Name _________________________________________________

Subscriber ID Number Group ID Number

__________________________ _____________________

Medical Questions, general. Please indicate all that apply

If you answer YES to any of the first 4 questions, please STOP and see receptionist:

* Do you have Diabetes? Yes No Don't Know

* Do you have Heart Disease? Yes No Don't Know

* Do you have any Artificial Joints or Artificial Heart Valves? Yes No Don't Know

* Are you in good health? Yes No Don't Know

* Have you ever had Radiation Therapy or Chemotherapy? Yes No Don't Know

Are you currently under the care of a physician?

Please Name ________________________________________________________________

Any changes to your general health in the last year? Yes No Don't Know

Date of last physical exam ____________________________

If yes, what is the condition being treated? ________________________________________

Have you had a serious illness, operation or been hospitalized in the last 5 years?

Yes No Don't Know

If yes, what was the illness or problem? ___________________________________________

Are you taking or have recently taken prescription or over the counter medications?

Yes No Don't Know

If yes, please list all including vitamins, natural or herbals preparations and/ or diet supplements or anything else the Dentist should be aware of: ___________________________________________________________________________

Allergies. Please indicate all those you are or have been allergic to, and if yes please indicate your reaction

Local Anesthetics Yes No Don't Know

Aspirin Yes No Don't Know

Penicillin or Any Other Antibiotics Yes No Don't Know

Barbiturates, Sedatives, or Sleeping Pills Yes No Don't Know

Sulfa Drugs Yes No Don't Know

Codeine or other Narcotics Yes No Don't Know

Metals Yes No Don't Know

Latex (rubber) Yes No Don't Know

Iodine Yes No Don't Know

Hay fever /Seasonal Yes No Don't Know

Animals Yes No Don't Know

Other Yes No Don't Know

Has a physician or dentist recommended that you take antibiotics prior to your dental treatment?

Yes No Don't Know

Name of physician or dentist ____________________________

Phone __________________

Women Only. Are you: Pregnant? Yes No Don't Know

If YES, number of weeks: _______________________________

Taking Birth Control Pills/ Hormone Replace? Yes No Don't Know

Nursing? Yes No Don't Know

Tobacco, Alcohol, Other. Do you use Controlled Substances? Yes No

Do you use tobacco or nicotine, in any form? Yes No

Do you use Alcohol? Yes No

How interested are you in Stopping? High Medium Low

How much in a day ______________ Times per week _________

Osteo-, Paget's, Other. Are you taking or scheduled to take either of the medications: Alendronate (Fosamax) or Risedronate (Actonel) for osteoporosis or Paget's disease?

Yes No Don't Know

Since 2001, were you treated or scheduled to intravenous bisphosphonates (Aredia/ Zometa) for osteoporosis, hypercalcemia or skeletal complications from Paget

Yes No Don't Know

AIDS/ HIV Positive

Alzheimer’s Disease

Anaphylaxis

Anemia

AnginaArthritis / Gout

Artificial Heart Valve

Artificial Joint

Asthma

Blood Disease

Blood Transfusion

Breathing Problems

Bruise Easily

Cancer

Chemotherapy

Chest Pains

Cold Sores / Fever Blisters

Congenital Heart Disorder

Convulsions

Cortisone Medicine

Drug Addiction

Easily Winded

Emphysema

Epilepsy or SeizuresExcessive Bleeding

Excessive ThirstFainting Spells / Dizziness

Frequent Cough

Frequent Diarrhea

Frequent HeadachesGenital Herpes

Glaucoma

Hay Fever

Heart Attack / Failure

Heart Murmur

Heart Pacemaker

Heart Trouble/ Disease

Hemophilia

Hepatitis A

Hepatitis B or C

Herpes

High Blood Pressure B

High Cholesterol

Conditions, Diseases. Please indicate all that apply

Atherosclerosis Autoimmune Disease

Been told you Stop Breathing

Been told you Snore

Consume Alcohol

Cardiovascular Disease

Crohn’s, Ulcerative Colitis

Depression, Depressive Episodes

Diabetes

Dizziness

Dry Mouth, Cracked Tongue

Had Physician Recommend a Sleep

Low Blood Pressure

Lung Disease

Mitral Valve Prolapse

Osteoporosis

Pain in Jaw Joints

Parathyroid Disease

Psychiatric Care

Radiation Treatments

Recent Weight loss

Renal Dialysis

Rheumatic Fever

Rheumatism

Scarlet Fever

Shingles

Sickle Cell Disease

Sinus Trouble

Spina BifidaStomach / Intestinal Disease

Stroke

Swelling of limbs

Other Heart (congenital) Defects

Pacemaker

Pneumonia

Resort to Mouth-Breathing

Smoker, Tobacco Use

Study, or had One Performed

Suffer from Daytime Drowsiness

Suffer from Nasal Obstruction in Sleep

Teeth Grinding

Thyroid Disease

Tonsillitis

Tuberculosis

Tumors or Growths

Ulcers

Venereal Disease

Yellow Jaundice

Wake up Un-Refreshed

Hives or Rash

Hypoglycemia

Irregular Heartbeat

Kidney ProblemsLeukemia

Liver Disease

Jaw Joint Pain

Jaw Clicking, Locking

Please list any and all Conditions or Diseases you may have, not listed here

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

Dentist's Notes, please keep this space clear

_______________________________________________________________________________

_______________________________________________________________________________

* Both Doctor and Patient are encouraged to discuss any and all relevant Patient Health issues prior to treatment.

I hereby certify that I have read and understand the above and that the information given on this form is accurate. I understand the importance of a truthful health history and that my dentist and staff will rely on this information for my treatment. I acknowledge that my questions, if any, about inquiries set forth above have been answered to my satisfaction. I will not hold my Dentist nor any member of staff, responsible for any action they take or do not take because of errors or omissions

that I may have made in the completion of this form.

Signature of Patient _________________________________ Date ______________________

Signature of Legal Guardian ___________________________ Date ______________________

Office of Keerthi Senthil DDS, MS

72027 Desert Drive, Rancho Mirage, CA 92270

(760) 340- 5107

Patient Rights- Access to Your Medical Records You have the right to look at or obtain copies of your health information, with limited exceptions. You may request that we provide copies in a format other than photocopies. We will use the format requested by you unless we cannot practicably do so. Please make this request in writing, to obtain your health information. We will charge a reasonable cost-based fee for expenses such as copies, information for a fee as well. Contact us for further information.

Privacy Practices Acknowledgment

I, _______________________________________ have received a copy of the Privacy Practices from

Keerthi Senthil, DDS, MS

Patient Name _______________________________________ Phone _________________________

Email _____________________________________

Address ___________________________________________________________________________

City __________________________ State ________________________ Zip ___________________

Patient Signature ______________________________________ Date ________________________ Witness Name _____________________________________________________________________

Witness Signature ____________________________________ Date _________________________

Consent for Services

You have the right as a patient, to be informed about your condition and the recommended dental, medical or diagnostic procedures to be used that you make the decision whether or not to undergo the procedure after knowing the risks involved. This disclosure is meant not to alarm you rather it is simply an effort to make you better informed so you may give or withhold your consent to a procedure.

I, ___________________________________ consent to be a patient of Keerthi Senthil, DDS, MS and agree to radiographic and clinical examination. I also understand the following:

1. During the course of treatment, I may undergo procedures in all places of dentistry and medicine, including periodontics (gum treatment and surgery), oral surgery, endodontics (root canals), fixed and removable prosthodontics (crowns, bridges and dentures), implant dentistry, restorative dentistry, temporomandibular disorder treatment, sleep apnea treatment, oral pathology, radiography, and saliva DNA testing.

Initials _____________________________________

2. I will provide a thorough and complete medical history, supply a full list of my medications with dosages, and consent to my dentist communicating with my other medical practitioners to inquire about any aspect of my health history.

Initials _____________________________________

3. No guarantee nor warranty can be made about treatment outcomes, restoration longevity, nor prognosis. I understand that any branch of medicine, including dentistry, can involve unanticipated results.

Initials _____________________________________

4. I will pay in advance any cost of treatment or insurance copayments according to the office's financial policy. I understand that even if an insurance pre-estimate is given or a procedure has been pre-approved, I am responsible for all costs of my insurance does not cover.

Initials _____________________________________

5. My treatment plan may change over time and I will do my best to approach my dental care with

optimism and open communication with my dentist, hygienist and dental office staff.

Initials _____________________________________

Financial Policy

Payment is due when services are rendered. For payment options, you may apply for a payment plan through Care Credit Dental Fee Plan, which must be arranged and approved in advance of your treatment appointment. As a courtesy to our patients who have dental insurance and medical insurance coverage, we will file your claim electronically. Your deductable and co-payment are due the day of service. Any amount exceeding your plan's annual maximum amount is due when service is rendered. Please give our office at least 24 hour's notice to cancel or re-schedule an appointment.

A minimum fee of $50.00 will be charged for missed appointments. We appreciate your cooperation, Thank You.

Signature ____________________________________ Date ___________________

Office of Keerthi Senthil DDS, MS

72027 Desert Drive, Rancho Mirage,CA 92270

(760) 340- 5107

Today’s Date:_______________

Sleep Health Questionnaire

Patient Name:

Last ____________________ Middle ____________________ First ________________________

Home Phone (include area code) _____________________

Work Phone (include area code) _____________________

Mobile Phone (include area code) ____________________

Address ____________________________________________________ City _________________

State ______________ Zip Code ______________ Email __________________________________

Mailing Address ___________________________________________________________________

Date of Birth __________________ Sex M__ F__ Height ____________ Weight _____________

Occupation _______________________________________________________________________

Employer Name, Address ____________________________________________________________

Marital Status: Single Married Divorced Separated

Social Security Number Emergency Contact Relationship to Patient

__________________ _______________ __________________

Their Home Phone Their Cell Phone

__________________ _______________

Have you ever fallen sleep or nodded off while driving? Yes No 6

Have you ever woken up suddenly with shortness of breath, gasping or with your heart racing?

Yes No 6

Do you feel excessively tired during the day? Yes No 4

Do you snore or have been told that you snore? Yes No 4

Have you had weight gain and found it difficult to lose? Yes No 2

Have you taken medication for, or been diagnosed with high blood pressure?

Yes No 2

Do you kick or jerk your legs while sleeping? Yes No 3

Do you feel burning, tingling or crawling sensation in your legs when you wake up?

Yes No 3

Do you wake up with headaches during the night or in the morning?

Yes No 3

Do you have trouble falling asleep? Yes No 4

Do you have trouble staying asleep once you fall asleep? Yes No 4

Have you been told you stop breathing in your sleep? Yes No 8

TOTAL SCORE: _______

Risk Level Score

Low 0-7

Medium 8-11

High 12-15

Severe 16+

Signs and Symptoms. Please indicate all that apply

__ Family History of Snoring or Sleep Apnea

__ Stroke/ Heart Disease

__ Un-refreshed Sleep

__ Depression __ Grind Teeth

__ Acid Reflux __ Hypertension

__ Snoring __ Diabetes

Sleep History. Please indicate all that apply

Have you ever been diagnosed with a Sleep Disorder? Yes No

Are you currently using a CPAP machine? Yes No

Do you use your CPAP less than 5 times a week? Yes No

Would you prefer an oral device or appliance? Yes No

Patient’s Signature _________________________________ Date______________________