• Patient Health Questionnaire
  • PATIENT INFORMATION
  • Date of completion
  • Mr. Ms. Miss. Mrs. Dr.
  • Name
  • First
  • Middle Initial
  • Last
  • Age
  • Date Of Birth
  • Referred by
  • DDS MD ENT DC OTHER
  • Location and/or Phone Number of Healthcare Provider:
  • Patient Address:
  • City:
  • State:
  • Zip:
  • Home Phone:
  • Alternate Contact Number:
  • Type of Employment:
  • Responsible Party (if different than Patient):
  • Address:
  • City:
  • State:
  • Zip:
  • Family Dentist:
  • Address and/or Phone:
  • Family Physician:
  • Address and/or Phone:
  • Reason(s) for this appointment:
  • Pain Sleep/Airway Orthodontics Unknown
  • 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.
  • Recent
  • Chronic (6 mo.+)
  • 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
  • Kicking or jerking leg 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
  • Other:
  • Other
  • Do you have concerns in any of these areas:
  • General Appearance
    Ability to Function
  • Overbite
    Smile
  • Other Comments:
  • Do any of the above complaints or concerns affect your daily life?
  • WHAT ARE THE RESULTS YOU ARE SEEKING FROM TREATMENT?
  • Signature
  • Date:


  • ALLERGIC REACTIONS
  • Please check any and all medications or substances that have caused an allergic reaction
  • Anesthetics
    Antibiotics
    Aspirin
    Barbiturates
  • Codeine
    Iodine
    Latex
    Metals
  • Penicillin
    Plastic
    Sedatives
    Sulfa
  • Other
  • CURRENT MEDICATIONS
  • Please list all medications you are taking and the reason you take them. Include all over-the-counter medications, vitamins, herbs, etc.
  • Medication
  • Dosage
  • Reason for Taking
  • See attached list
  • PREVIOUS TREATMENTS/MEDICATIONS FOR THE CONDITION WE ARE EVALUATING
  • Treatment and/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.
  • Patient Signature:
  • Date:
  • Parent/Guardian Signature (if patient is a minor):
  • Date:
  • HEALTH AND MEDICAL HISTORY
  • YES NO
  • Are you currently pregnant?
  • YES NO
  • Have you sustained injury to:
  • Head Neck Face Teeth Other
    • YES NO
    • Do you drink 4 or more cups of coffee per day?
    • YES NO
    • Have you had prior orthodontic treatments?
    • YES NO
    • Trouble breathing through nose
    • YES NO
    • No Do you smoke tobacco?
    • YES NO
    • No Consume alcohol or take sedatives
      (for pain relief or sleeping)
  • Patient Signature:
  • Date:
  • HEALTH AND MEDICAL HISTORY (CONTINUED)
  • Do you have, or have you experienced any of the following:
    • Yes No
      Heart Disorder/Heart Attack
      Heart
      Mitral Valve Prolapse
      Heart Pacemaker
      Heart Palpitations
      Heart Valve Replacement
      Irregular Heartbeat
      Blood Pressure
    • HIGH LOW
    • Stroke
      Bleeding Easily
      Bruising Easily
      Cancer of
    • Chemo Radiation
    • Anemia
      Asthma
      Birth Defects
      Diabetes
      Epilepsy
      Emphysema
      Glaucoma
      Gastroesophageal Reflux(GERD)
      Hemophilia
      Hepatitis
      History of Substance Abuse
      Hypoglycemia
      Huntington's Disease
      Kidney Disease
      Liver Disease
      Leukemia
      Migraines
      Meniere's Disease
      Multiple Sclerosis
      Muscular Dystrophy
      Neuralgia
      Osteoarthritis
      Osteoporosis
      Ovarian Cyst
      Parkinson's Disease
      Rheumatic Fever
      Rheumatoid Arthritis
      Scarlet Fever
    • Yes No
      Thyroid Problems
      Tuberculosis
      Intestinal Disorder
      Nervous System Disorder
      Anxiety
      Skin Disorder
      Urinary Tract Disorder
      Chronic Fatigue
      Fibromyalgia
      Cold Hands and Feet
      Depression
      Difficulty Concentrating
      Difficulty Breathing at Night for Sleep
      Dizziness
      Excessive Thirst
      Fainting
      Fluid Retention
      Frequent Cough
      Frequent Ear Infection
      Frequent Sore Throat
    • Frequent awaking at night
    • Hearing Impairment
      Memory Loss
      Hay Fever
      Insomnia
      Muscle Aches
      Muscle Fatigue
      Muscle Tremors
      Poor Circulation
      Psychiatric Care
      Recent Weight Gain
      Recent Weight Loss
      Sinus Problem
      Shortness of Breath
      Slow Healing Sores
      Speech Difficulties
      Swollen Stiff or Painful Joints
      Tired Muscles
  • Additionla Information
  • SURGICAL HISTORY
  • Have you had any of the following:
    • Yes No
      General Anesthesia
      Adenoids removed
      Tonsils removed
      Jaw joint Surgery
    • Yes No
      Orthognathic Surgery
      Oral Surgery
    • Removal of third molar (wisdom teeth) Other
    • Other Surgery
    • Please list below
  • Othertype Of Surgery
  • Signature
  • Date:
  • CURRENT SYMPTOMS
  • Head Pain
  • Location Recent Chronic Severity Duration Frequency
    L=Left  R=Right  B=Bilateral (over 6 mo.) Mild  Mod  Severe Min.  Hrs.  Days Occasional  Frequent  Constat
    L R B
    Frontal (Forehead)
    Recent
    Chronic
    Mild Mod Severe
    Min Hrs Days
    Occasional Frequent Constant
    L R B
    Generatdzed
    Recent
    Chronic
    Mild Mod Severe
    Min Hrs Days
    Occasional Frequent Constant
    L R B
    Parietal (Top of head)
    Recent
    Chronic
    Mild Mod Severe
    Min Hrs Days
    Occasional Frequent Constant
    L R B
    Occipital (Back of head)
    Recent
    Chronic
    Mild Mod Severe
    Min Hrs Days
    Occasional Frequent Constant
    L R B
    Temporal (Temple area)
    Recent
    Chronic
    Mild Mod Severe
    Min Hrs Days
    Occasional Frequent Constant
  • Do you have pain or discomfort in any of the following areas ? If so, please indicate the approximate date the pain began.
    • Jaw Pain
    • Jaw Joint Sounds
    • L R
    • Jaw pain with opening
    • L R
    • Jaw pain when chewing
    • L R
    • Jaw pain at rest
    • L R
    • Jaw sounds with opening
    • L R
    • Jaw sounds when chewing
    • L R
    • Jaw sounds at rest
    • Jaw Locking
    • Jaw Joint Symptoms
    • YES NO
    • Jaw locks closed
    • YES NO
    • Jaw locks open
    • YES NO
    • Teeth clenching
    • Day Night
    • YES NO
    • Teeth grinding
    • Day Night
  • Eye Related Conditions
    • YES NO
    • No Blurred vision
    • YES NO
    • No Double vision
    • YES NO
    • No Eye pain
    • YES NO
    • Pain or pressure behind the eyes
    • YES NO
    • Extreme sensitivity to light (photophobia)
    • YES NO
    • Wear of glasses or contact lenses
  • Ear Related Conditions
    • L R
    • Buzzing in the ears
    • L R
    • Ear congestion
    • L R
    • Earpain
    • L R
    • Hearing loss
    • L R
    • Itchiness or Stuffiness in ears
    • L R
    • Pain behind the ear
    • L R
    • Pain in front of the ear
    • L R
    • Recurrent ear infections
    • L R
    • Ringing in the ear (Tinnitus)
  • Throat Related Conditions
    • YES NO
    • Chronic sore throat
    • YES NO
    • Difficulty swallowing
    • YES NO
    • Swollen glands
    • YES NO
    • Thyroid enlargement
    • YES NO
    • Tightness in throat
    • YES NO
    • Constant feeling of a foreign object in throat
  • Neck Related Conditions
    • YES NO
    • Limited movement of neck
    • YES NO
    • Neck pain
    • YES NO
    • Numbness in hands or fingers
    • YES NO
    • Swelling in the neck
  • Signature
  • Date:
  • Shoulder Related Conditions
    • YES NO
    • Shoulder pain
    • YES NO
    • Shoulder stiffness
    • YES NO
    • Tingling in hands or fingers
  • Back Related Conditions
    • YES NO
    • Back pain - lower
    • YES NO
    • Back pain - middle
    • YES NO
    • Back pain - upper
    • YES NO
    • Sciatica
    • YES NO
    • Scoliosis
  • Mouth and Nose Related Conditions
    • YES NO
    • Dry mouth
    • YES NO
    • No Chronic sinusitis
    • YES NO
    • No Frequent snoring
    • YES NO
    • Burning tongue
    • YES NO
    • Broken teeth
    • YES NO
    • No Frequent biting of the cheek
  • 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
  • Average hours of sleep per night?
    • ls it easy to fall asleep?
    • YES NO
    • Do you feel rested upon AM waking?
    • YES NO
    • Stopped breathing during sleep?
    • YES NO
    • Do you wake often during the night?
    • YES NO
    • Gasping or Choking 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'?
  • YES NO
  • Does any family member have the same or similar problem'? If yes, please explain.
  • Can you relate your pain or condition to a motor vehicle accident or traumatic injury'?
  • 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 msurance coverage.
  • Patient Signature:
  • Date:
  • Parent/Guardian Signature (if patient is a minor):
  • Date:
  • Indicate Areas of Pain in below images
  • Following the Pain Scale: 1. Mild pain 2. Moderate pain 3. Severe pain
  • 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.
  • 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
    • 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
  • Patient Name:
  • Date:
  • Night time Sleepiness Evaluation
  • Screening Tool for Sleep Apnea
  • Developed by David While, M.D., Harvard Medical School, Boston, MA
  • Please answer the following questions.
  • 1. Snoring
  • a) Do you snore on most night (> 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 (1)
  • No (0)
  • Total
  • Name
  • Date
  • AUTHORIZATION TO RELEASE INFORMATION TO THE BELOW
  • LISTED REFERRING AND TREATING HEALTH CARE
  • PROFESSIONALS:
  • Doctors 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.
  • Patient Signature:
  • Date:
dental dental
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