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  • 2322 196th St. SW, Suite 201 Lynnwood, WA 98036 | Call Us Today! 206-316-8286

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Adult Patient Form

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New Patient - Adult Form

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Please explain your reason for seeking treatment so that we may best meet your needs

Allergies

Please list and medication/substances which have caused an allergic reaction
Allergy List*

Medications

Please list and medications currently being taken
Medication List
Name
Dosage
Frequency
Reason
 

Dental History

Do you bite your nails?*
For Kids: Have you in the past or present used a pacifier or sucked on your fingers?*
Have you had any orthodontic treatment?*
Have you had any oral surgery?*
Have you ever been told you have periodontal (gum) disease?*
Are you satisfied with the appearance of your teeth/smile?*

Health History

Are you currently pregnant?*
Do you smoke/chew tabacco?*
Do you consume alcohol/take sedatives?*
Do you drink 4 or more cups of coffee, soda, or energy drinks a day?*
Have you sustained injury to your
Do you have trouble breathing through your nose?*
Do you sleep with your mouth open?*

Do you have, or have you experienced any of the following?

Do you have, or have you experienced any of the following?*

Back Related Conditions

Back Related Conditions*

Shoulder Related Conditions

Shoulder Related Conditions*

Mouth and Nose Related Conditions

Mouth and Nose Related Conditions*
Does your tongue rest between your teeth?*
Does your tongue fit in the roof of your mouth?*

Sleep Conditions

Do you snore frequently?*
Is it easy to fall asleep?*
Do you feel rested in the morning?*
Have you stopped breathing during sleep?*
Do you wake often during the night?*
Do you wake gasping or coughing during the night?*
Have you ever had a sleep study?*

Chief Compaints

What are the chief complaints for which you are seeking treatment? Please number your complains with #1 being the most severe, #2 being the next most severe, etc. Then rate your complaints for frequency and intensity (0-10, 10 being the most severe pain).
Per Month
Please enter a number from 0 to 10.
Per Month
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Per Month
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Per Month
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Per Month
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Per Month
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Per Month
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Per Month
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Per Month
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Per Month
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Per Month
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Per Month
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Per Month
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Per Month
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Per Month
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Per Month
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Per Month
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Per Month
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Do you have concerns in any of these areas?*

Symptoms

Do you have any of the following symptoms?
Head Pain (generalized)*
Head Pain (front of your head)*
Head Pain (top of your head)*
Head Pain (back of your head)*
Pain in your templates*
Jaw Pain (On opening)*
Jaw Pain (While chewing)*
Jaw Pain (At rest)*
Jaw Popping*
Jaw Clicking*
Jaw Locks (Closed)*
Jaw Locks (Open)*
Teeth Grinding*
Burning Tongue*
Frequent biting of the cheek*
Frequent Snoring*
Teeth Clenching*
Dry Mouth*
Back Pain (Upper)*
Back Pain (Middle)*
Back Pain (Lower)*
Shoulder Pain*
Shoulder Stiffness*
Morning Hoarseness*
Swelling in ankles or feet*
Dry mouth upon waking*
Buzzing in the ears*
Tinnitus (ringing in the ears)*
Ear pain*
Ear Congestion*
Pain in front of the ear*
Pain behind the ear*
Hearing loss*
Recurrent ear infections*
Blurred vision*
Eye pain*
Pain/pressure behind eyes*
Swelling in the neck*
Swollen glands*
Thyroid enlargement*
Tightness in the throat*
Tingling in the hands or fingers*
Numbness in the hands or fingers*
Chronic sinusitis*
Chronic sore throat*
Difficulty swallowing*
Limited movement of the neck*
Neck pain*
Kicking or jerking leg repeatedly*
Tossing or turning frequently while sleeping*
Repeated awakening*
Affects sleep of others*
Heart palpitations*
Poor concentration*
Memory loss*
Difficulty sleeping*
Excessive need for sleep*
Fatigue*
Weak muscles*
Sore Muscles*
Agitation / anxiety*
Depression*
Dry skin*
Itchy Skin*
Sweating*
Difficulty tolerating heat*
Unusual hair loss*
Dry hair*
Cracking nails*
Infrequent/hard bowel movements*
Frequent/loose bowel movements*
Unexpected weight loss*
Unexpected weight gain*
Persistent pain/swelling in front of neck*
Sensation of lump in your throat*
Eye pain or double vision*
Change in facial appearance*
Difficulty tolerating cold*
Difficulty tolerating cold*
Hand tremors*

For women before Menopause only:

Loss of menstrual periods
Excessive menstrual flow
Irregular periods
Have you need pregnant or miscarried during the past 2 years?

History of symptoms

History of Treatment

Please list any treatments you have had for this problem, and all healthcare professionals that you are currently seeing:
History
Practitioner Name
Approx Date
Specialty
Treatment
 

Head Pain History

Which side are your headaches worse on?*
Where do your headaches spread to?
When having pain do you experience any of the following?

The Epworth Sleepiness Scale

How likely are you to doze off or fall asleep in the following situations?
0 = No chance of dozing
1 = Slight change of dozing
2 = Moderate chance of dozing
3 = High change of dozing
Sitting and reading*
Watching TV*
Sitting inactive in a public place*
As a passenger in a car for an hour without a break*
Lying down to rest in the afternoon when curcumstances permit*
Sitting and talking to someone*
Sitting quietly after lunch without alcohol*
In a car while stopped for a few minutes in traffic*

STOP-BANG Nighttime Questionnaire

STOP

Do you SNORE loudly (louder than talking or loud enough to be heard through closed doors)?*
Do you often feel TIRED, fatigued, or sleepy during daytime?*
Has anyone OBSERVED you stop breathing during your sleep?*
Have you or are you being treated for high blood PRESSURE?*

BANG

BMI more than 35kg/m2?*
AGE over 50 years old?*
NECK curcumference > 16 inches (40cm)?*
GENDER: Male?*

Social Media Confidentiality / Non-Disclosure Agreement

During my treatment with Dr. David Buck & Balance Epigenetic Orthodontics, I acknowledge confidentiality is an important component of privacy. Patients share some of their most sensitive personal information with their physicians and physicians, in turn, have an obligation to ensure the information entrusted to them is kept secure and confidential.

Dr. David Buck & Balance Epigenetic Orthodontics recognizes that the internet provides unique opportunities to participate in interactive discussions and share information on particular topics using a wide variety of social media, such as Facebook, Twitter, blogs, and wikis. However, patients' use of social media can pose risks to Dr. David Buck & Balance Epigenetic Orthodontics’ confidential and proprietary information and reputation and can jeopardize our compliance with medical practice laws.

Posting any pictures directly related to your treatment and any pictures taken in Dr. Buck’s office is strictly prohibited. If this is violated Dr. David Buck & Balance Epigenetic Orthodontics may terminate any and all further treatment with you as a patient.

Discussing your treatment on social media, in our experience, produces unnecessary worry, fear, doubt and potentially hysteria which all undermine our provider-patient relationship. Treatment questions, concerns, problems or uncertainties must be addressed to Dr. Buck and/or office team and must not be posted to any social media.

CONSENT FOR USE AND DISCLOSURE OF HEALTH INFORMATION

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. Conversations within our office between providers, administrative staff and patients may be recorded for training and/or quality of care purposes.

Notice of Privacy Practices: You have the right to read our Notice of Privacy Practices 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. A 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:

Contact Person: Dr. S. David Buck
Phone number: (425)-361-7499
Address: 2322 196th Street SW Suite 201, Lynnwood, WA. 98036

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 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, ad that we may decline to treat you or to continue treating you if you revoke this consent. I have had the 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 healthcare operations.

If this consent is signed by a personal representative on behalf of the patient, complete the following: