Congratulations! I am so happy that you’ve taken this important step and made the incredible decision to move forward with your treatment. The very reason I decided to limit my practice is to help patients with and sleep problems achieve true happiness, and I commend you for embracing the bright future you want. You are worth it!

Coming from a family of physicians, I learned at a young age the importance and impact of good healthcare. Several years ago, I developed craniofacial pain and decided to learn more about treating it. During my learning process, I noticed in my specialty practice of Periodontics, Implantology and Endodontics, that many of my patients had similar problems. After treatment, several commented that their quality of life had improved. I developed a passion to help people from a myriad of symptoms related to Sleep and TMJ Disorders. By treating these issues and helping patients achieve greater rest and pain free days, I’ve seen whole lives turn around. Now that is something to get excited about! It is heartbreaking to watch people delay the care they need, and that is why I am so impressed and inspired that you have selected to move forward with your treatment. Again, A HUGE CONGRATULATIONS to you for embracing life, and getting the world-class care you deserve. To maximize our time together, please complete the medical intake forms and return to our office 24 hours prior to your appointment. You can email them to [email protected] or fax to (972) 538-3751.

We are about to take an amazing journey together, and I can promise you that the time you spend with us will be memorable, enjoyable and inspiring. You’ll be in the very best hands while you’re here, and I’m certain you are going to love the results.

Sincerely,

Dr. Shab Krish DDS, MS, DABCP, DABCDSM INSTRUCTIONS FOR YOUR 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 and shoulders with nonmetal clips or bands. Jewelry and piercings will need to be removed from the neck and ears if possible. Please no heavy perfume or cologne.

If you have any questions or concerns, please ask or call the office at 972-538-3777. We are here to help.

What NOT to wear: What to wear:

Long sleeve shirt Short sleeve shirt Hair down Hair pulled back Ears hidden Ears visible Jewelry/piercings No headband/clips Collared shirt No jewelry/piercings Heavy perfume No collar No heavy cologne/perfume NOTICE OF PRIVACY PRACTICES

This 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.

We want you to know about the policies and procedures which we In Patient Reminders developed to make sure your health information will not be shared with Because regular care is very important in your treatment, we will remind anyone who does not require it. 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 Our office is subject to State and Federal law regarding the follow up on your care and inform you of treatment options or confidentiality of your health information and in keeping with these services that may be of interest to you. These communications are an laws, we want you to understand our procedures and your rights as our important part of our philosophy of partnering with our patients to valuable patient. ensure they receive the best quality care.

We will use and communicate your HEAL TH INFORMATION only for Abuse or Neglect the purposes of providing your treatment, obtaining payment and We will notify government authorities if we believe a patient is the conducting health care operations. Your health information will not be victim of abuse, neglect or domestic violence. We will make this used for other purposes unless we have asked for and been voluntarily disclosure only when we are compelled by our ethical judgment, given your written permission. when we believe we are specifically required or authorized by law or with the patient’s agreement.

HOW YOUR HEALTH INFORMATION MAY BE USED Public Health and National Security We may be required to disclose Federal officials or military authorities’ To Provide Treatment health information necessary to complete an investigation related We will use your HEALTH INFORMATION within our office to to public health or national security. Health information could be provide you with the best care possible. This may include administrative important when the government believes that the public safety could and clinical office procedures designed to optimize scheduling benefit when the information could lead to the control or prevention of and coordination of care between hygienist, dental assistant, dentist, an epidemic or the understanding of new side effects of a drug and business office staff. In addition, we may share your health treatment or medial device. information with physicians, referring dentists, clinical and dental laboratories, pharmacies or other health care personnel providing For Law Enforcement treatment. As permitted or required by State or Federal law, we may disclose your health information to a law enforcement official for certain law To Obtain Payment enforcement purposes, including, under certain limited circumstances, if We may include your health information with an invoice used to collect you are a victim of a crime or in order to report a crime. 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 Family, Friends and Caregivers will be sure to only work with companies with a similar commitment We may share your health information with those you tell us will be to the security of your health information. helping you with your treatment, medications or payments. We will be sure to ask your permission first. In the case of an emergency, To Conduct Health Care Operations where you are unable to tell us what you want we will use our Your health information may be used during performance very best judgment when sharing your health information only when evaluations of our staff. Some of our best teaching opportunities use it will be important to those participating in providing care. clinical situations, experienced by patients receiving care at our office. As a result, health information may be included in training Authorization to Use or Disclose Health Information Other than is stated programs for students, interns, associates, and business and clinical above or where Federal, State or Local law requires us, we will not employees. It is also possible that health information will be disclosed disclose your health information other than with your written during audits by insurance companies or government appointed authorization. You may revoke that authorization in writing at any time. 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. PATIENT RIGHTS

This new law is careful to describe that you have the following rights Your request may be denied if the health information record in question related to your health information. 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 Restrictions complete. You have the right to request restrictions on certain uses and disclosures or your health information. Our office will make every effort to Documentation of Health Information honor reasonable restriction preferences from our patients. 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 Confidential Communications treat-ment, payment or health operations. Our documentation procedures You have the right to request that we communicate with you in a certain will enable us to provide information on health information usage from way. You may request that we only communicate your April 14, 2003 and forward. Please let us know in writing the health information privately with no other family members present or time period for which you are interested. Thank you for limiting your through mailed communications that are sealed. We will make every request to no more than six years at a time. We may need to effort to honor your reasonable requests for confidential charge you a reasonable fee for your request. 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. I have read, understand, agree and consent to following policies (Please initial each section and sign at the bottom of this page):

Private Patient Agreement I am aware that Shab R. Krish, DDS, MS and the TMJ & Sleep Therapy Centre of North Texas are not contracted with my insurance company. I am requesting to be seen as a patient and completely understand I will be responsible for full fees on a private pay basis. I agree to pay for treatment services by Shab R. Krish, DDS, MS at the fee schedule based on the private practice charges. ____

HIPAA – Privacy Practices I hereby acknowledge that I have received a copy of TMJ & Sleep Therapy Centre of North Texas’ Notice of Privacy Practices. Additionally, I authorize release of this same information to other providers rendering medical/dental care, as well as to labs that need my information to make a diagnosis, treatment and/or to fabricate an appliance necessary for my treatment. I also agree for my information to be provided or obtained for the processing of insurance claims. ____

Telephone Consumer Protection Act (TCPA) Consent I give my expressed consent to TMJ & Sleep Therapy Centre of North Texas to service my account or collect any amount I owe by telephone, at any telephone number associated with this or any other account held by the Practice. This includes wireless telephone numbers, which could result in charges to me. TMJ & Sleep Therapy Centre of North Texas may also contact me by sending text messages or e-mails using any phone number or e-mail address I provide to the Practice. ____

Permission to Use Photographs & X-Rays I consent to the taking of photographs and x-rays before, during and after treatment as they are a necessary part of the diagnostic procedure and record keeping. I further give permission for the use of these photographs, x-rays and records to be used for the purpose of research, education or publication in professional journals. ____

Financial Responsibility Additionally, I understand that payment is immediately due when services are rendered. If amounts due to the healthcare providers are not paid after reasonable notice and healthcare provider's efforts to collect, then the account will be considered delinquent – and additional service charges may be added to the account balance to offset additional incurred collection expenses. In the event that I avoid or refuse to pay or that I default on agreed payment arrangements and terms, I understand that I will be responsible for any and all reasonable attorneys’ and legal fees, court costs, and incurred collection costs and expenses. ____

Cancellation/Refund Policy As not to delay appointments for other scheduled patients, we reserve the right to reschedule your appointment if you arrive 15 minutes after your scheduled appointment. Additionally, appointments canceled without a 48-hour notice are subject to a $50 cancellation fee. No refunds or exchanges for completed or in- process treatment will be provided, as our treatment consists of custom-made durable medical equipment and it is NONREFUNDABLE once ordered. ____

Patient’s Printed Name: ______

Signature: ______Date: ______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 first 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 list them in order from #1 to #6, with #1 being your biggest complaint and so on.

Example:

Do you currently experience any of the following symptoms? Please check off any symptoms Recent Chronic Recent Chronic (inside your head) Morning Hoarseness Headache (outside your head) Breathing through your mouth Jaw Pain Dry Mouth Upon Wakening Jaw Locking Fatigue Chewing Pain Difficulty Falling Asleep Face Pain Tossing and Turning Frequently Eye Pain Repeated Awakening Throat Pain Feeling Unrefreshed in the Morning Shoulder Pain Nighttime Urination Night Sweats Dyskinesia Vivid Dreams Difficulty Opening Mouth Sore Jaw Upon Awakening Difficulty Closing Mouth Significant Daytime Drowsiness Noises in Jaw Joints Affect Sleep of Others Ear Stuffiness Short of Breath when Waking Dizziness Told “I stop breathing” During Sleep Ringing in Ears (Tinnitus) Night-Time Choking Spells Unable to Vision Problems EXAMPLEtolerate C-Pap Muscle Spasms Tooth Grinding Sinus Congestion Teeth Crowding Swelling in ankles or feet Frequent Heavy Snoring Numbness (localized) Acid Indigestion Nerve Pain Kicking or jerking leg repeatedly Dental Changes Any other symptoms not listed above Teeth Spacing Teeth Sensitivity Changes with your bite

Out of the symptoms listed above, please list top six symptoms, only one per line 1. Jaw Pain 2. Jaw locking 3. Muscle spasms 4. Night-time choking spells 5. Neck pain 6. Numbness Comprehensive Health Questionnaire Patient Information Mr. Ms. Miss Mrs. Dr. Patient Name: Phone: Age: Date of Birth: Height: Weight: Referred by: DDS MD DO DC Other 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): 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:

Do you currently experience any of the following symptoms? Please check off any symptoms Recent Chronic Recent Chronic Headache (inside your head) Morning Hoarseness Headache (outside your head) Breathing through your mouth Jaw Pain Dry Mouth Upon Wakening Jaw Locking Fatigue Chewing Pain Difficulty Falling Asleep Face Pain Tossing and Turning Frequently Eye Pain Repeated Awakening Throat Pain Feeling Unrefreshed in the Morning Neck Pain Morning Headaches Shoulder Pain Nighttime Urination Back Pain Night Sweats Dyskinesia Vivid Dreams Difficulty Opening Mouth Sore Jaw Upon Awakening Difficulty Closing Mouth Significant Daytime Drowsiness Noises in Jaw Joints Affect Sleep of Others Ear Stuffiness Short of Breath when Waking Dizziness Told “I stop breathing” During Sleep Ringing in Ears (Tinnitus) Night-Time Choking Spells Unable Vision Problems to tolerate C-Pap Muscle Spasms Tooth Grinding Sinus Congestion Teeth Crowding Swelling in ankles or feet Frequent Heavy Snoring Numbness (localized) Acid Indigestion Nerve Pain Kicking or jerking leg repeatedly Dental Changes Any other symptoms not listed above Teeth Spacing Teeth Sensitivity Changes with your bite

Out of the symptoms listed above, please list top six symptoms, only one per line 1. 2. 3. 4. 5. 6.

Patient/Parent Signature: Date: 1 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? Side Back Stomach Varies Sleep Location? Bed Couch Chair Other Bed Partner? Yes No Average hours of sleep per night? Is it easy to fall asleep? Yes No Average hours of sleep per day? Do you wake often during the night? Yes No Cough, gasps or snorts on waking? Yes No Do you feel rested upon waking? Yes No Observed pauses in breath? Yes No Stopped breathing during sleep? Yes No Have you ever had a Sleep Study? HST PSG No Date: Result: Previous Positive Airway Pressure Devices Used? CPAP BiPAP ASV APAP Do you currently use a PAP Device? Yes No Type: Previous Oral Appliance? Yes No Type: Allergic Reactions Please check any and all medications or substances that have caused an allergic reaction

Anesthetics Antibiotics Aspirin Barbiturates Codeine Iodine Latex Metals Plastics Penicillin Sedatives Sulfa Food Allergies/Sensitivities 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

See attached list 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)

See attached list Health And Medical History Are you currently pregnant? Yes No Do you drink 4 or more cups of coffee per day? Yes No Do you smoke tobacco? Yes No Do you consume alcohol or take sedatives? Yes No Do you have trouble breathing through your nose? Yes No Have you had prior orthodontic treatments? Yes No Have you sustained injury to: Head Neck Face Teeth Other: Surgical History -Have you had any of the following: General Yes No Orthognathic Surgery Yes No Adenoids Removed Yes No Oral Surgery Yes No Tonsils Removed Yes No Removal of Third Molar Yes No Jaw Joint Surgery Yes No (Wisdom Teeth) Other types of surgery:

Patient/Parent Signature: Date:

2 Additional Health And Medical History Do you have or have you experienced any of the following - please include any family history

Yes No Fam HX Yes No Fam HX Anemia Hypoglycemia Anxiety Insomnia Asthma Intestinal Disorder Bleeding Easily Irregular Heartbeat Birth Defects Kidney Disease Bruising Easily Leukemia of ______Liver Disease Chemo Low Blood Pressure Chronic Fatigue Meniere’s Disease Cold Hands and Feet Memory Loss COPD Migraines Depression Mitral Valve Prolapse Diabetes Multiple Sclerosis Difficulty Concentrating Muscle Aches Difficulty Breathing at Night Muscle Fatigue Dizziness Muscle Spasms Emphysema Muscular Dystrophy Epilepsy Excessive Thirst Nervous system Disorder Fainting Osteoarthritis Fibromyalgia Fluid Retention Ovarian Cyst Frequent Colds/Flu Parkinson’s Disease Frequent Cough Poor Circulation Frequent Ear Infection Psychiatric Care Frequent Radiation Awakening from Sleep Recent Weight Gain Gastroesophageal Reflux Recent Weight Loss Glaucoma Rheumatic Fever Hay Fever Rheumatoid Arthritis Hearing Impairment Scarlet Fever Attack Shortness of Breath Heart Disease Skin Disorder Heart Murmur Sinus Problems Heart Pacemaker Slow Healing Sores Heart Palpitations Speech Difficulties Heart Valve Replacement Stroke Hemophilia Swollen or Painful Joints Hepatitis Thyroid Disease High Blood Pressure Tired Muscles History of Substance Abuse Tuberculosis Huntington’s Disease Urinary Tract Disorder

Patient/Parent Signature: Date: 3 Additional Symptoms

Location Recent Chronic Severity Duration Frequency L=Left R=Right B=Bilateral Over 6mo. Mild Mod Severe Hrs Days Wks Occ. Freq Constant Head Pain Temple Area L R B Back of Head L R B Forehead L R B Top of Head L R B All of Head L R B

Jaw Pain Jaw Joint Sound Jaw pain with opening L R Jaw sounds with opening L R Jaw pain when chewing L R Jaw sounds when chewing L R Jaw pain at rest L R

Jaw Locking Jaw Joint Symptoms Jaw locks closed Yes No Teeth clenching Yes No Day Night Jaw locks open Yes No Teeth grinding Yes No Day Night

Eye Related Conditions Pain or pressure behind the eyes Yes No Blurred vision Yes No Extreme sensitivity to light Yes No Double vision Yes No Wears glasses or contacts Yes No Eye pain Yes No

Ear Related Condition Buzzing in ears L R Pain behind ear L R Ear Pain L R Pain in front of the ear L R Ear Congestion L R Recurrent ear infections L R Hearing loss L R Ringing in the ear (tinnitus) L R Itchiness/stuffiness L R

Throat Related Conditions Chronic sore throat Yes No Thyroid enlargement Yes No Difficulty swallowing Yes No Tightness in throat Yes No Swollen glands Yes No Feeling of foreign object in throat Yes No

Neck Related Conditions Limited movement Yes No Numbness in hands/fingers Yes No Neck pain Yes No Swelling in neck Yes No

Shoulder Conditions Pain in shoulder Yes No Tingling in fingers/hands Yes No Stiffness in shoulder Yes No

Back Conditions Yes No Yes No Middle back pain Yes No Yes No Upper back pain Yes No

Mouth/Nose Conditions Chronic sinusitis Yes No Broken teeth Yes No Dry mouth Yes No Biting cheeks Yes No Frequent snoring Yes No Burning tongue Yes No

Patient/Parent Signature: Date: 4

Patient/Parent Signature: 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? Yes No If yes, what conditions: Date of accident: Does any family member have a sleep breathing disorder? Yes No If yes, explain:

Adult - Complete this section

1. DAYTIME SLEEPINESS EVALUATION - 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 Score Situation Score Sitting and reading Sitting and talking to someone Watching Television Sitting quietly after lunch (no alcohol) Sitting, inactive in a public place In a car, while stopped for a few minutes in traffic As a passenger in a car for an hour without a break Lying down to rest in the afternoon when circumstances permit TOTAL SCORE

2. NIGHTTIME SLEEPINESS EVALUATION Developed by David White, M.D., Harvard Medical School, Boston, MA 1.Snoring Score 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? Yes (2) No (0) TOTAL SCORE

Patient/Parent Signature: Date: 5 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 thas o a se f age-appropriate “trigger questions” fro u e sin t e hc linical interview. B = bedtime problems E = excessive daytime sleepiness A = awakenings during the night R = regularity and duration of sleep S = snoring

(P) Parent-directed question Does your child (P) (C) Child-directed question Do you (C) Symptom Age Age Age Toddler/Preschool School Age Adolescent (2-5 years) (6-12 years) (13-18 years) 1. Bedtime Problems Does your child have any Does your child have any Do you have any problems falling problems going to bed? problems at bedtime? asleep at bedtime? (P) Y N (P) Y N (C) Y N

Do you have any problems going to bed? (C) Y N

2. Excessive Daytime Sleepiness Does your child seem overtired or Does your child have difficulty Do you feel sleepy a lot during the sleepy a lot during the day? waking in the morning; seem day? (C) Y N (P) Y N sleepy during the day or take naps? (P) Y N In school? (C) Y N

Do you feel tired a lot? While driving? (C) Y N (C) Y N

3. Awakenings during the night Does your child wake up a lot at Does your child seem to wake up a Do you wake up a lot at night? night? (P) Y N lot at night? (P) Y N (C) Y N

Any sleepwalking or nightmares? (P) Y N Have trouble getting back to sleep? (C) Y N Do you wake up a lot at night? (C) Y N

Have trouble getting back to sleep? (C) Y N

4. Regularity and duration of sleep Does your child have a regular What time does your child go to What time do you usually go to bed on bedtime and wake time? bed and get up on school days? school nights? (C) (P) Y N (P) Weekends? (C) What are they? (P) Weekends? (P) How much sleep do you usually Do you think he/she is getting get? (C) enough sleep? (P) Y N

5. Snoring Does your child snore a lot or have Does your child have loud or Does your teenager snore loudly difficult breathing at night? nightly snoring or any breathing or nightly? (P) Y N (P) Y N difficulties at night? (P) Y N

Source: “A Clinical Guide to Pediatric Sleep: Diagnosis and Management of Sleep Problems” by Jodi A. Mindell and Judith A. Owens; Lippincott Williams & Wilkins

Patient/Parent Signature: Date: 6 Pain Location

Middle of Face Back of Head

Lower Face Neck

Right Side of Head Left Side of Head

7 AUTHORIZATION TO RELEASE INFORMATION TO REFERRING AND TREATING HEALTH CARE PROVIDERS AND/OR FAMILY MEMBERS

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.

Patient/Parent Signature: Date:

8