TMD Health History

Please note that it is important to fill in all the fields before submitting. Thank you.

Patient Name :
*Last Name:
 Middle Name: *First Name:
*Your birthday :
Sex: Male Female SS# :
Marital Status :
*Home address :
City :
State :
Zip :
Apt# :
*Email address :
*Home Phone : ()--
Cell# : ()--
Work# : ()---
If patient is a minor, parent or guardian details -
His/Her Name : Phone # : ()--
In case of emergency contact detals -
His/Her Name : Phone # : ()--
Relationship :
Your Physician : Phone # : ()--
Subscriber's employment information -
Name of employer :
Address : City :
State : Zip :
MEDICAL INSURANCE INFORMATION
Primary Medical Insurance -
Company Name : Phone # : ()--
Subscriber's name : Birthday :
Relationship to patient : Self Spouse Child Other SSN :
Group Number : Policy #: Effective date:
Secondary Medical Insurance -
Company Name : Phone # : ()--
Subscriber's name : Birthday :
Relationship to patient : Self Spouse Child Other SSN :
Group Number : Policy #: Effective date:
Auto Insurance Information -
Carrier name : Claim #:
Date of Accident :
Address : City :
State : Zip :
Adjuster's Name : Phone # : ()--
Whom may we thank for referring you? Yellow Pages Internet Friend/Family
Other :
Consent To Treatment -
* I consent to the treatment which may be performed in the office and which may include but is not limited to laboratory procedures, x-rays, examination(s) and other services rendered under the general and special instructions of my doctor or assistants/designees. I will be responsible for communicating any special care needs or limitations of treatment to my doctor or care giver.
Release Of Medical Information -
* I authorize this office to furnish any information and records regarding this specific visit including information regarding psychiatric, substance abuse and communicable disease as follows; a) to any person or corporation that I indicate is responsible for paying my health care bills or that may be liable under a contract with me to pay my health care bills. This consent automatically expires when all records requirements for payment of my bills have been met, b) Health care providers have access to my health care records as needed for purposes of continuity of care.
Patient's Autosization To Release Medical Information And Clam Payment -
* I hereby authorize the Headache, Neck & Facial Pain Clinic to release any information regarding services rendered by them and to allow a photocopy of my signature to be used to file my Medicare and/or insurance claim, and any third party payer.
** Please Note: The following statement applies to all types of insurance except Medicare.
Due to the many changes in insurance policies, it is no longer an easy task to interpret each individual policy. Therefore, we urge you, the patient, to check with your insurance company prior to any treatment. Failure to comply with this suggestion could result in you, the patient, being responsible for all costs incurred.
PATIENT HEALTH HISTORY
Dr. Martin Fraschetti, DDS, FICCMO, in association with Metropolitan Imaging Center, primarily treats patients for head, neck, facial pain. Because of our concern for you, we are obligated to ask the following questions. Please take the time to answer them as accurately as possible. The information you provide is considered confidential, but necessary to help you with your problems. Please bring all forms with you t o your first appointment.
Height : Weight : Race :
What is your chief compliant?
How did your pain start?
When did pain start?
What caused it?

Employment Unemployed Employed Full Time Employed Part Time Retired Student Military
Tobacco None Rarely Moderately Daily
Alcohol None Rarely Moderately Daily
Drugs None Rarely Moderately Daily
Caffeine None Less than 3 cups a day 3 to 6 cups a day More than 6 cups a day
Exercise None Very Little Moderate Regular
Physical Activity None Very Little Moderate Regular
Social Activity None Very Little Moderate Regular

MEDICAL HISTORY
Immunizations
None Do Not Know Tetanus Pertussis Diphtheria
Polio Measles Rubella Mumps

Childhood Diseases
None Do Not Know Measles Rubella Mumps
Whooping Cough Chicken Pox Rheumatic Fever Polio Scarlet Fever

Operations
None
Appendectomy
Breast Surgery
Breast Biopsy
By-Pass Surgery
Caesarean
Cancer Surgery
Ear Surgery
Eye Surgery
Gall Bladder Surgery
Gastrointestinal Surgery
Heart Surgery
Hernia Surgery
Hysterectomy
Joint Replacement Surgery
Liver Surgery
Lung Surgery
Neurosurgery
Nose Surgery
Oral Surgery
Periodontal Surgery
Prostate Surgery
Spleen Surgery
Sleep Apnea Surgery
Thyroid Surgery
Tonsillectomy

Diagnosed as Having
None
Addisons Disease
Anemia
Anorexia
Arteriosclerosis
Arthritis
Asthma
Bronchitis
Bulimia
Cancer
cataract
Colitis
Coronary Aretery Disease
Chronic Fatigue
Depression
Diabetes
Emphysema
Endometriosis
Epilepsy/Seizures
Fibromyalgia
Gall Bladder Disease
Glaucoma
Goiter
Heart Attack
Heart Disease
Hemophilia
Hepatitis
Herpes
HIV / AIDS
Hypoglycemia
Hypertension
Irritable Bowel Syndrome
Kidney Trouble
Leukemia
Lime Disease
Liver Disease
Fibromyalgia
Mitral Valve Prolapse/Murmur
Multiple Sclerosis
Osteoporosis
Parathyroid Trouble
Parkinson's Disease
Rheumatic Fever
Rhumetism
Sickle Cell Anemia
Sleep Apnea
Stomach Ulcers
Stroke
Tumors
Thyroid Problem
Tuberculosis
Venereal Disease
CURRENT HEALTH
Pregnant : Yes No Due Date :
Your Physical Health : Good Fair Poor Your Mental Health : Good Fair Poor

Medical Allergies
None Penicillin Erythromycin Other Antibiotics
Iodine Spinal Anesthetics Barbiturates Sulfa Drugs
Aspirin Aspirin Substitutes NSAIDS Local anesthetics
Sedatives / Sleeping Pills

Environmental Allergies
None Acrylic Animal Hair Feathers
Latex Rubber Metal Pollen Dairy Products
Dust / Molds Food Additives Grasses Trees
Wheat / Cereals

Current Medications
None Antibiotics Anticoagulants Antidepressants
Antihistamines Aspirin Cortisone Digitalis
Dilantin Flouride Gel / Drops Sulfa Drugs Hormones
Insulin Muscle Relaxants Nitroglycerine NSAIDS
Oral Contraceptives Penicillin Salivary Substitutes Sleep Medication
High Blood Pressure Medicine

Current Practioners (doctors you have seen in the last year)
None Acupuncturist Allergist Alternative Health Care
Behavioral Medicine Cardiologist Chiropractor Endocrinologist
Endodontist ENT General Dentist Internist
Neurologist Neurosurgeon Nutritionist Ob / Gyn
Ophthalmologist Optometrist Surgeon (general) Orthodontist
Orthopedic Surgeon Osteopathic Physician Periodontist Physiatrist
Physical Therapist Prosthodontist Psychiatrist Psychologist
Rheumatologist Oral / Maxillofacial Surgeon


REVIEW OF SYSTEMS
Cardiovascular :
No Positive Findings Chest Pain Shortness of Breath Taken Diet Pills (Fen-Phen, Redux)
Fainting Spells High Blood Pressure Low Blood Pressure Ankles Swell during the Day
Heart Beats Faster Pacemaker Heart Skips a Beat Heart Beats Irregularly

Musculoskeletal :
No Positive Findings Painful Joints Swollen Joints Aches in Joints
Painful Muscles Aches in Muscles Stiff Movement Jaw Joint Problems
Painful Movement Difficulty Walking Trouble Getting out of a Chair

Ears Nose & Throat :
No Positive Findings Nasal Obstruction Difficulty Hearing Difficulty Swallowing
Nasal Injury Snoring Uses Hearing Aid Dizziness / Vertigo
Nasal Polyps Pain in Ears Sinus Infections Frequent Sore Throats
Lumps in Neck Area Ringing in Ears Burning of Tongue Swollen Glands
Hoarseness Nosebleeds Voice Changes Infection in Ears

Constitutional :
No Positive Findings Anxiety Fever Chills
Weight Gain Weight Loss Physical Fatigue Physical Weakness
Depression

Endocrine :
No Positive Findings Feel Tired most of the Time
Restless most of the Time Frequent Dry Mouth
Urinate more than 6 Times a Day Recent Unwanted Weight Loss
Recent Unwanted Weight Gain Thirsty Most of the Time
Always Hungry

Skin :
No Positive Findings Acne Hives Excessive Sweating
Rashes Hair Loss Dry Skin Slow Healing Wounds
Flushing, Hot Flashes

Respiratory :
No Positive Findings Stuffy Nose Chest Congestion Cough Up Blood
Hay Fever Persistent Cough Sinus Problems Difficulty Breathing
Breathe through the Mouth

Gastrointestinal :
No Positive Findings Constipation Diarrhea Irritable Bowel
Nausea Vomiting Stomach Problems

Neurological :
No Positive Findings Blackouts Forgetfulness Frequent Headaches
Seizures Tingling in Limbs

Immunological :
No Positive Findings Chills Fever Frequent Cold Sores
Swollen Glands in the Neck

Hemopoietic :
No Positive Findings Bruise Easily Prolonged Bleeding Slow to Heal after Cuts
Heavy Periods Frequent Nose Bleeds

Ophthamological :
No Positive Findings Wears Eyeglasses Wears Contacts Difficulty with Vision
Eye Disease Blurred or Double Vision

Genitourinary :
No Positive Findings Kidney Problems Difficulty Urinating Frequent Urination
Excessive Urination


Family history

Father’s Health :
Do Not Know Alive - Healthy Alive - In poor health Deceased – Natural Causes
Deceased - Accident Deceased - Disease Age at Death

Father’s Diseases :
None Do Not Know Diabetes TB
Heart Disease Hypertension Stroke Prostate Cancer
Cancer Breast Cancer Oral Cancer Kidney Problems
Arthritis Anemia Headaches Mental Illness
TMD/TMJ Problems Symptoms like mine

Mother’s Health :
Do Not Know Alive - Healthy Alive - In poor health Deceased – Natural Causes
Deceased - Accident Deceased - Disease Age at Death

Mother’s Diseases :
None Do Not Know Diabetes TB
Heart Disease Hypertension Stroke Prostate Cancer
Cancer Breast Cancer Oral Cancer Kidney Problems
Arthritis Anemia Headaches Mental Illness
TMD/TMJ Problems Symptoms like mine

Head and Neck Pain
Area Right Side Left Side
Intensity 0-10 Sometimes Often Constant Intensity 0-10 Sometimes Often Constant
Top of Head
Front of Head
Temple
Back of Head
Eye & Sinus
Jaw Joint
Ear
Behind the Ear
Side of Jaw
Under Side of Jaw
Maxillary Teeth
Mandibular Teeth
Front of Neck
Lateral Neck
Back of Neck
Shoulder


*Signature :
Date :