Confidential Patient Information

Today's Date:
First Name:
Middle Initial:
Last Name:
Gender:
Birthdate:
Age
Address:
City:
State:
Zip:
Symptoms:
(1) Review the entire form before filling out.
(2) Start with the questions/answers you know for sure.
(3) On the remaining questions, take a couple of days to be self aware of any symptoms you may have not noticed prior, then complete the form.
A. HEAD, NECK, AND FACE SYMPTOMS: Fill in the appropriate response bubble indicating whether or not you currently have, previously had, or never had the following conditions or symptoms, and identify a right side or left side location where appropriate.
1. Painful or sore teeth
2. Teeth sensitive to hot or cold
3. Gum disease or bleeding gums
4. Oral surgery
5. Wisdom teeth removed
6. Caprs or crowns on teeth
7. Teeth ground by dentist
8. Chew gum
9. Have you eer had orthodontic treatment?
10. Have you ever had periodontal disease (pyorrhea)?
11. Have you ever been treated for a bad bite?
12. Do you have missing back teeth and no replacements?
13. Do you feel that your bite is closed?
14. Do you feel that there is enough room for your tongue?
15. Are any of your teeth worn badly?
16. Are any of your teeth very loose?
17. Have you had teeth extracted within the past three years?
18. Accident to teeth?
19. Accident to jaws?
20. Accident to face?
Pain
21. Do you have tension headaches?
22. Do you ever have migraine headaches?
23. Are there times when you notice that this problem or pain is less or gone completely?
24. Do you feel that you need treatment for this problem?
25. Do your teeth hurt from clenching or chewing?
26. Does the pain or discomfort disturb your sleep?
27. Is there constant or recurring pain?
Left or Right?
28. Would you describe the pain as a dull, aching sensation?
Left or Right?
29. Would you describe the pain as a stabbing, sharp, severe sensation?
Left or Right?
30. Does your jaw ache when you chew?
31. Does your jaw hurt when you open wide or take a big bite?
32. Do you have ear pain?
Left or Right?
33. Do you have pain in front of the ears?
Left or Right?
34. Do you suffer from chronic headaches?
35. Have you ever had chronic shoulder or back pain?
Left or Right?
36. Pain in teeth on arising?
Left or Right?
37. Headaches in left or right temple?
Left or Right?
38. Headaches in back of head?
39. Generalized facial pain?
40. Degree of pain same in morning as evening?
Left or Right?
41. Chronic stiff neck?
42. Neckaches (neck pain)?
43. Does it now hurt to open wide?
44. Are your symptoms worse:



45. Have you ever been operated on for pain?
46. Did the operation bring relief from pain?
47. Have you ever had injections or nerve blocks for pain?
48. Did any of the injections bring relief from pain?
49. How often do you take medicine for relief of pain?



TMJ SYMPTOMS
50. Can't open mouth all the way
51. Mouth goes to one side when fully opened
52. Grind teeth during night
53. Numbness of shoulder, arms, hands, fingers
54. Shoulder pain
55. Has your jaw ever locked so you were unable to open or close?
56. Did your jaw ever make any noise?
57. Have you ever been treated for problems of your jaw joint or for facial muscle spasms?
58. Do you ever awaken with awareness of your teeth or jaws?
59. Are you aware of clenching your teeth during the day?
60. Do you have difficulty in opening your mouth widely?
61. Do you have difficulty in swallowing?
62. Have you ever had pain in your jaw joint?
63. Do you ever hear grating sounds from your jaw joint?
64. Do you ever hear or feel a clicking or popping from your jaw joint?
65. Does your jaw make clicking or popping sounds when you chew?
66. Does your jaw feel tired after a big meal?
67. Has anyone heard you grinding your teeth in your sleep?
68. Has anyone heard you grinding your teeth during the daytime?
69. Are you aware that you clench your teeth during the night?
70. Does it now hurt to open wide?
71. Does it ever hurt to open wide?
EARS
72. Itchiness or stuffiness in ears?
73. Ringing, hissing, or buzzing sounds in ears?
74. Grating noise in ears (like sand particles)?
75. Earaches or ear pain?
76. Hearing loss?
77. Throbbing or whooshing sound in ears?
BREATHING
78. Allergies?
79. Sinus problems?
80. Nose stuffed when you have a cold?
81. Nose runs when you don't have a cold?
82. Snore?
83. Mouthbreather?
FOOD ALLERGIES: Please completely fill in the appropriate response bubble indicating if you have allergic response to any of the following foods.
1. Dairy products
2. Wheat, cereals
3. Dyes in food
4. Other
PRACTITIONERS: Since your pain began, which of the following people have you seen for treatment and pain relief?
1. Acupuncturist
2. Allergist
3. Anesthesiologist
4. Cardiologist (heart)
5. Chiropractor
6. Clergyman
7. Dentist
8. Dermatologist (skin)
9. Dietician
10. Ear, Nose, or Throat
11. Endocrinologist
12. Faith healer
13. Family physician
14. Gynecologist/obstetrician
15. Hypnotist
16. Internist
17. Naturopath
18. Neurologist
19. Neurosurgeon
20. Nutritionist
21. Opthalmologist (eyes)
22. Optometrist
23. Orthopedist (bones, joints)
24. Orthodontist
25. Osteopathic physician
26. Pediatrician (children)
27. Physical therapist
28. Plastic surgeon
29. Proctologist
30. Psychiatrist
31. Psychologist
32. Radiologist
33. Rheumatologist
34. Surgeon
35. Other
PAIN SUMMARY: Please identify your areas of pain on the diagrams below indicating right and/or left.
FACE
Back
Front
POSTURE
84. Abnormal curvatur of the spine?
85. Backaches?
86. Unequal leg length?
87. Inability to sit still for prolonged time?
88. Do you cradle the phone between your head and shoulders?
89. Does your work involve typing/word processing?
90. Do you wear high heels?

EYES
91. Pain in, around, or behind the eyes?
92. Eyelid tics (twitches)?
93. Eyes blink or water most of the time?
94. Eyesight blurs?
EQUILIBRIUM
95. Dizziness or lightheadedness?
96. Often naeuseated (feel like vomiting)?
TRAUMA
97. Accident or trauma to head.
98. Accident or trauma to face.
99. Accident or trauma to jaw.
100. Accident or trauma to neck.
101. Whiplash neck injury?
102. Cervical traction neck collar?
103. Have you ever received a severe blow to the side of the head or jaw?
104. Was there a strain or stretching of the jaw such as yawning, during a dental procedure; while chewing or opening the mouth wide?
105. Broken jaw?
106. Have you experienced a fall within the last three years?
LIFESTYLE
107. Do you feel you are under a lot of stress?
108. Do you usually eat breakfast?
109. Do you bite your nails, tongue, or lips?
110. Any mood affecting drugs or stimulants?
111. Do you exercise regulary?
112. Do you work more than 40 hours a week?
MEDICAL HISTORY
1. Arteriosclerosis
2. Rheumatoid arthritis
3. Swollen, stiff or painful joints
4. Osteoarthritis (neck, joints, etc.)
5. Heart trouble
6. Heart murmur
7. Pains or tightness in chest
8. Low blood pressure (hypotension)
9. High blood pressure (hypertension)
10. Fainting spells or feeling faint
11. Feel exhausted or fatigued most of the time
12. Swollen ankles or feet
13. Hands get cold
14. Bruise easily
15. Slow healing sores
16. Muscle soreness or stiffness
17. Hand tremors
18. Diabetes
19. More thirsty than usual lately
20. High or low blood sugar
21. Sugar in urine
22. Blood in urine
23. Shortness of breath
24. Use extra pillows to help breathing at night
25. Hard to concentrate or remember
26. Difficulty falling asleep or staying asleep
27. Frequently irritable
28. Endocrine or hormone problems
29. Cancer
30. Any history of substance use or abuse
31. Numbness of arms or hands
32. Asthma
33. AIDS
34. Autoimmune disorder
35. Hepatitis
MEDICINES: Completely fill in the response bubble indicating whether you are sensitive or allergic to or are now taking any of the following medications.
1. Heart pills (Digitails, etc.)
2. Nerve pills
3. Diet pills - diuretics
4. Pain pills (Demerol, Codeine, etc.)
5. Vitamins
6. Birth control pills
7. Sleeping pills
8. Muscle relaxants
9. Insulin
10. Other
Additional Notes: