Patient Health Questionnaire

Patient Information

What is the chief complaint for which you are seeking treatment in our office?

Indicate how important each complaint is and whether it is a current concern.

Treatment goalYesNo
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
Treatment goalYesNo
Kicking or jerking legs repeatedly
Swelling in ankles or feet
Morning hoarseness
Dry mouth upon waking
Fatigue
Difficulty falling asleep
Tossing and turning frequently
Repeated awakening
Feeling unrefreshed in the morning
Significant daytime drowsiness
Frequent heavy snoring
Affects sleep of others
Gasping when waking
Told that I stop breathing during sleep
Night-time choking spells
Unable to tolerate C-Pap
Tooth grinding
Teeth crowding
Signature

Allergic Reactions

Please check any and all medications or substances that have caused an allergic reaction.

Current Medications

Prescription / supplementDosageReason for taking

Previous Treatment / Medications for the Condition We Are Evaluating

Treatment and/or medicationDate treated or takenApproximate cost of treatment
Patient signature

Health and Medical History

Have you ever had a serious illness, operation, or hospitalization?
Have you ever taken Fosamax or any bisphosphonate medication?
Are you allergic or sensitive to any medications or materials?
Are you taking blood thinners?
Do you smoke or use tobacco products?
Do you use alcohol or recreational drugs?
Are you pregnant or nursing?
Do you need antibiotic pre-medication before dental treatment?

Health and Medical History Conditions

Current Symptoms

Please check the symptoms you currently experience.

Head Pain
Left temple pain
Frontal forehead
Pressure top of head
Occipital back of head
Sub-occipital pain
Jaw Pain
Jaw pain with yawning
Jaw pain with chewing
Jaw pain at rest
Jaw Joint Sounds
Jaw sounds with opening
Jaw sounds with chewing
Jaw sounds at rest
Jaw Locking
Jaw locks closed
Jaw locks open
Limited opening
Jaw Joint Symptoms
Jaw has catching or clicking
Jaw is painful to use
Jaw feels tired or sore
Eye Related Conditions
Eye pain
Eye congestion
Light sensitivity
Blurred vision
Ear Related Conditions
Ear pain
Ear congestion
Tinnitus
Dizziness or balance issues
Throat Related Conditions
Sore throat
Swallowing pain
Voice changes
Neck Related Conditions
Neck pain
Neck tension
Head-forward posture
Shoulder Related Conditions
Shoulder pain
Tingling or numbness in fingers
Back Related Conditions
Low back pain
Mid back pain
Mouth and Nose Related Conditions
Mouth breathing
Dry mouth
Nasal congestion
Sleep Conditions
Snoring
Witnessed apnea
Morning headaches
Daytime fatigue

History of Symptoms

Patient / guardian signature

Indicate areas of pain in blank images

Following the Pain Scale. 1. Mild pain 2. Moderate pain 3. Severe pain

Daytime Sleepiness Evaluation - Epworth Sleepiness Scale

How likely are you to doze off or fall asleep in the following situations?

SituationScore 0-3
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
Sitting and talking to someone
Sitting quietly after lunch without alcohol
In a car while stopped in traffic

Night Time Sleepiness Evaluation

Authorization to Release Information to the Below

Patient signature