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: Please enter code above in the field below.