TMJ & Sleep New Patient Registration Form

Please note that it is important to fill in all the fields before submitting. Thank you.
Title : Mr Mrs Ms Dr
Patient Name :
Last Name*
Middle Name First Name*
Birthday:*
Age:
Patient Address:*
City
State
Zip
Apt#
Home Phone:* ()--
Alt. Contact:* ()--
Employer:
Reffered By : DDS MD ENT DC Other
Health Care Provider
Location : Phone #: ()--
Family Dentist : Phone #: ()--
Address: City
State Zip
Family Physician: Phone #: ()--
Address: City
State Zip
Reason(s) for this appointment: Pain Sleep/Airway Orthodontics Unknown
If different than Patient
Responsible Party:
Address: City
State Zip
Apt#

What is the Chief Complaint for Which You are Seeking Treatment in Our Office?
Note- Please Identify Your Chief Complaint as #1, List All Other Symptoms in Priority #2-9
Select the Priority Recent Chronic (6 mo.+)
Headache Pain
Ear Pain
Jaw Pain
Pain when chewing
Facial Pain
Eye Pain
Throat Pain
Neck Pain
Shoulder Pain
Back Pain
Limited ability to open mouth
Jaw joint locking
Jaw joint noises
Ear congestion
Sinus congestion
Dizziness
Tinnitus (ringing in the ears)
Muscle twitching
Vision problems
Difficulty falling asleep
Swelling in ankles or feet
Morning Hoarseness
Dry mouth upon waking
Fatigue
Kicking or jerking leg repeatedly
Repeated awakening
Tossing and turning frequently
Tooth grinding
Significant daytime drwosiness
Frequent heavy snoring
Affects sleep of others
Gasping when waking
Teeth crowding
Night-time choking spells
Unable to tolerate C-Pap
Told that "I stop breathing" during sleep
Feeling unrefreshed in the morning
Other :
Do you have concerns in any of these areas : General Appearance Overbite
Ability to Function Smile
Other Comments:
Do any of the above complaints or concerns affect your daily life?
What are the Results You are Seeking from Treatment?
ALLERGIC REACTIONS
Please check any and all medications or substances that have caused an allergic reaction
Anesthetics Codeine Penicillin
Antibiotics Lodine Plastic
Aspirin Latex Sedatives
Barbituates Metals Sulfa
Other :
CURRENT MEDICATIONS
Medication Dosage Reason of Taking
PREVIOUS TREATMNET/MEDICATIONS FOR THE CONDITION WE ARE EVALUATING
Treatment &/or Medication Doctor/Provider Name Approximate Date of Treatment
* I release and give my permission for this office to request information and communicate with the providers listed above.
HEALTH AND MEDICAL HISTORY
Are you currently pregnant? Yes No
Have you sustained injury to: Head Neck Face Teath Yes No
Other:
Do you drink 4 or more cups of coffee per day? Yes No
Do you smoke tobacco? Yes No
Have you had prior orthodontic treatments? Yes No
Consume alcohol or take sedatives? Yes No
Trouble breathing through noe? Yes No
HEALTH AND MEDICAL HISTORY
Do you have, or have you experienced any of the following:
Yes No Heart Disorder/ Heart Attack Yes No Thyroid Problem
Yes No Heart Murmur Yes No Tuberculosis
Yes No Mitral Valve prolaps Yes No Intestinal Disorder
Yes No Heart Pacemaker Yes No Nervous System Disorder
Yes No Heart Palpitations Yes No Anxiety
Yes No Heart Valve Replacement Yes No Skin Disorder
Yes No Irregular Heartbeat Yes No Urinary Tract Disorder
Yes No Blood Pressure High Low Yes No Chronic Fatigue
Yes No Stroke Yes No Fibromyalgia
Yes No Bleeding Easily Yes No Cold hands and feet
Yes No Bruising Easily Yes No Depression
Yes No Difficulty concentrating Yes No Scarlet Fever
Yes No Difficulty breathing at night for sleep Yes No Hemophilia
Yes No Anemia Yes No Dizziness
Yes No Asthma Yes No Excessive Thirst
Yes No Birth Defects Yes No Fainting
Yes No Diabetes Yes No Fluid Retention
Yes No Epilepsy Yes No Frequent colds/flu
Yes No Emphysema Yes No Frequent cough
Yes No Glaucoma Yes No Frequent ear infections
Yes No Gastroesophpgeal Reflex(Gerd) Yes No Frequent sore throat
Yes No Hepatitis Yes No Hearing impairment
Yes No History of Substance Abuse Yes No Memory Loss
Yes No Hypoglyeemia Yes No Hay Fever
Yes No Huntington's Disease Yes No Insomnia
Yes No Kidney Disease Yes No Muscle aches
Yes No Liver Disease Yes No Muscle fatigue
Yes No Leukemia Yes No Muscle spansms
Yes No Migraines Yes No Muscle tremors
Yes No Meniere's Disease Yes No Poor circulation
Yes No Multiple Sclerosis Yes No Psychiatric Care
Yes No Muscular Dystrophy Yes No Recent weight gain
Yes No Neuralgia Yes No Recent weight loss
Yes No Osteoarthritis Yes No Sinus problems
Yes No Osteoporosis Yes No Shortness of breath
Yes No Ovarian Cyst Yes No Slow healing sores
Yes No Parkinson's Disease Yes No Speech difficulties
Yes No Rheumatic Fever Yes No Swollen, shiff or painful joints
Yes No Rheumatoid Arthritis Yes No Tired muscles
Yes No Cancer of Chemo Radiation
Yes No Frequent awaking at night - number of times :
Additional Information :
SURGICAL HISTORY
Have you had any of the following:
Yes No General Anesthesia Yes No Adenoids removed
Yes No Tonsils removed Yes No Jaw Joint Surgery
Yes No Orthognathic Surgery Yes No Other Surgery
Yes No Oral Surgery Removal of third molar(wisdom teeth) Other
Other types of surgery :
CURRENT SYMPTOMS
Head Pain -
Location Recent Chronic Severity Duration Frequency
L-left     R-Right     B-Bilateral (Over 6 mo.) Mid Mod Severe Min. Hrs. Days Occasional Frequent Constant
L R B Frontal (Forehead)
L R B Generalized
L R B Parietal (Top of head)
L R B Occipital (Back of head)
L R B Temporal (Temple area)
Jaw Pain -
L R Jaw pain with opening          L R Jaw pain when chewing
L R Jaw pain at rest
Jaw Joint Pain -
L R Jaw sounds with opening          L R Jaw sounds when chewing
L R Jaw sounds at rest
Jaw Locking -
Yes No Jaw locks closed Yes No Jaw locks open
Jaw Joint Symptoms -
Yes No Teeth clenching Day Night
Yes No Teeth grinding Day Night
Eye Related Conditions
Yes No Blurred vision Yes No Eye pain
Yes No Double vision Yes No Pain or pressure behind the eyes
Yes No Wear of glasses or contact lenses
Yes No Extreme sensitivity to light (photophobia)
Ear Related Conditions
Yes No Buzzing in the ears Yes No Pain behind the ear
Yes No Ear congestion Yes No Pain in front of the ear
Yes No Ear pain Yes No Recurrent ear infections
Yes No Hearing loss Yes No Ringing in the ear(Tinnitus)
Yes No Itchiness or Stuffiness in ears
Throat Related Conditions
Yes No Chronic sore throat Yes No Thyroid enlargement
Yes No Difficulty swallowing Yes No Tightness in throat
Yes No Swollen glands
Yes No Constant feeling of a foreign object in throat
Neck Related Conditions
Yes No Neck pain Yes No Numbness in hands or fingers
Yes No Swelling in the neck
Yes No Limited movement of neck
Shoulder Related Conditions
Yes No Shoulder pain Yes No Tingling in hands or fingers
Yes No Shoulder stiffness
Back Related Conditions
Yes No Back pain - lower Yes No Sciatica
Yes No Back pain - middle Yes No Scoliosis
Yes No Back pain - upper
Mouth and Nose Related Conditions
Yes No Dry mouth Yes No Burning tongue
Yes No Chronic sinusitis Yes No Broken teeth
Yes No Frequent snoring Yes No Frequent biting of the check
Sleep Conditions
Please select Yes or No answers based on your average sleep experience and/or what a sleep partner has told you.
Sleep Positions Side Back Stomach Varies
Is it easy to fall asleep? Yes No
Do you wake often during the night? Yes No
Do you feel rested upon AM waking? Yes No
Gasping or Choking during sleep? Yes No
Stopped breathing during sleep? Yes No
Have you ever had a Sleep Study (PSG)? Yes No
Result was:
HISTORY OF SYMPTOMS
On what date, or approximate date, did this condition or symptoms first occur?
Does any family member have the same or similar problem? Yes No
If yes, Please Explain :
Can you relate your pain or condition to a motor vehicle accident or traumatic injury? Yes No
If yes, please complete Trauma History Section, enclosed as a separate form:
* I authorize the release of all examination findings and diagnosis, report and treatment plans, etc., to any referring or treating health care provider. I additionally authorize the release of any medical information to insurance companies, or for legal documentation to process claims. I understand that I am responsible for all charges incurred for my treatment regardless of insurance coverage.
INDICATE AREAS OF PAIN
Front Back
Right Side Left Side



Authorization to Release Information To the below listed referring and Treating Health Care Professionals
DOCTOR'S NAME LOCATION PHONE
()--
()--
()--
()--
()--
()--
()--
* I authorize the release of communications regarding my treatment with
including a full report of examination findings, diagnosis, treatment plan, and progress reports to the providers listed above.

Daytime Sleepiness Evaluation - Epworth Sleepiness Scale
The Epworth Sleepiness Scale was developed. and validated by Dr. Murray Johns of Melbourne Australia. It is a simple, self-administered questionnaire - widely used by sleep professionals in quantifying the level of daytime sleepiness.
SITUATION SCORE
Sitting and Reading
Watching Television
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 circumstances permit
Sitting and talking to someone
Sitting quietly after a lunch without alcohol
In a car, while stopped for a few minutes in traffic
Total Score :

Night Time Sleepiness Evaluation - Screening Tool for Sleep Apnea
1. Snoring
a. Do you snore on most night (>3 nights per week)?
b. Is your snoring loud? Can it be heard through a door or wall?
2. Has it ever been reported to you that you stop breathing or gasp during sleep?
3. What is your collar size?
Male :
Female :
4. Do you occasionally fall asleep during the day when :
a. You are busy or active?
b. You are diving or stoppted at a light
5. Have you had or are you being treated for high blood pressure?
Total Score :
* 9 poits or more : Refer to sleep specialist or order sleep study.
* 6-8 points : Gray area, use clinical judgment.
* 5 point or less : Low probability or sleep apnea.


*Signature
Date
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