PATIENT INFORMATION FORM
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1 S S S PATIENT INFOATION FO S I S I E I I I t t SS t E Y E E /S t S t S t S t t? t t t S t t I S E I t t t S ESY E E t t t J t t I? Y / I t t SS S? Y / S I S t t S SS t I t / t t t t t t I / t t E t Y E SS t t I t t I t St t t t SS t I t St t t t t t? I p b t t t p p d S t t t t t t I t t
2 TJ QUESTIONNAIE DATE: NAE: I. EDICA / DENTA HISTOY A. General Health: 1. Physical Good 2. Emotional Good B. Do you have a personal physician? C. Are you currently under the care of a physician? D. Have you ever been seriously ill? E. Have you been hospitalized in the past 5 years? F. Have you ever had a major operation? G. Women: Are you pregnant? H. Has there been any change in your general health in the last year Fair Fair Poor Poor HIV / AIDS / AC (circle) Jaundice Kidney Disease igraine headaches usculo skeletal disorder Neurological disorder Psychiatric disorder heumatic fever Sleep disturbance (snoring, night gasping) Stroke Venereal Disease. edications currently taken by the patient? ne Antibiotics Birth control pills/hormones Diet Pills (Diuretics) Heart Pills (Digitalis, etc.) Insulin uscle elaxants (Valium, etc.) Pain Pills (Demerol, Codeine, etc.) Sleeping pills (Barbiturates) Tranquilizers (Valium, etc.). Allergies to medicine and/or food?: I. Has there been a major weight loss, without dieting, in recent months? J. Worried about receiving medical/dental treatment? K. Have you now, or in the past, experienced any of the following medical conditions?: Allergies Addiction Anemia (low blood cell count) Arthritis Asthma Arteriosclerosis Bleeding Problems Blood Diseases Blood Pressure high Blood Pressure low Blood Transfusions Bone Disorder Breathing or ung Disorder Cancer Chronic pain condition Diabetes Dizziness Drug/substance abuse Epilepsy Endocrine problems Female problems Gastrointestinal (GI) problems (ulcers) Genitourinary problems Heart Disease Hearing disorder, ringing ears Hepatitis ne Antibiotics Dairy Products Dental anesthetics Dyes in foods etals Pain pills Wheat, cereals II. CANIOFACIA SYPTOS OF THE HEAD, NECK AND FACE Fill in the appropriate response square indicating whether or not you currently have, or previously had, the following conditions or symptoms, and identify which side, right side of where appropriate. If both sides are involved, mark right and left sides. Current Condition 1. Bleeding gums and/or gum disease? 2. Crowns on teeth and/or cap s? 3. Do you chew gum regularly? 4. Do you feel that your bite cl osed? 5. Do you feel that there is not enough room for your tongue? 6. issing back teeth with no replacement? 7. Oral Surgery? 8. Orthodontic treatment? 9. Periodontal disease (Pyrrohea)? 10. Sore or painful teeth? 11. Teeth sensitive to cold and/or hot? 12. Teeth badly worn? 13. Teeth have been ground by dentist? 14. Teeth feel very loose?
3 15. Teeth extracted within the past three years? 16. TJ (jaw joint) treatme nt? 17. Treated for a bad bite? 18. Wisdom teeth remove d?. 19. Do you have frequent canker sores or cold sores? A. CANIOFACIA PAIN 1. Do you have generalized facial pain? 2. On which side is there constant or recurring pain? 3. Does the pain or discomfort disturb your sleep? 4. Would you describe the pain as a dull, aching sensation? 5. Would you describe the pain as stabbing, sharp, severe sensation? 6. Do you suffer from chronic headache? 7. Do you ever have migraine headaches? 8. Do you have tension headaches? 9. Headaches in right or left temple? 10. Headaches in the back of the head? 11. Are there times when you notice that the pain or problems are less or gone completely? 12. Do you have pain in teeth on awakening? 13. Do you r teeth hurt from clenching or chewing? 14. Does your jaw ache when you chew? 15. Does your jaw hurt when you open wide or take a big bite? 16. Does it now hurt to open wide? 17. Do you have ear pain? 18. Do you have pain in front of the ears? 19. Is the degree of pain same in morning as evenings? 20. Do you have chronic stiff neck? 21. Do you have neckaches (neck pain)? 22. Have you ever had chronic shoulder or back pain? 23. When are your symptoms worse?: Upon rising in the morning At work At the end of the workday At home At school 24. Have you ever been treated for pain? 25. Have you ever had injections or nerve blocks for pain? 26. Did any of the injections bring relief from pain? 27. Have you ever been operated on to relieve pain? 28. Did the operation bring relief from pain? 29. How often do you take medicine for the relief of pain? Never Seldom (a few times a year) Occasionally (once a month) Often (weekly) Frequently (daily) B. BEATHING POBES 1. Allergies? 2. Does your nose feel stuffy when you don t have a cold? 3. Does your nose run when you don t have a cold? 4. Sinus problems? 5. Do you snore? 6. outh breather? 7. Do you have sleep apnea? C. EYE POBES 1. Pain in, around, or behind eyes? 2. Eyesight blurs? 3. Eyelid tics (twitches)? 4. Eyes blink excessively? 5. Do your eyes water most of the time (tearing)? D. EA POBES 1. Earaches or ear pain? 2. Hearing loss? 3. Grating noise in ears (like sand particles)? 4. Itchiness in ears? 5. Stuffiness in ears? 6. inging, hissing, or buzzing sounds in ears? 7. Whooshing or throbbing sound in ears? E. EQUIIBIU POBES 1. Do you feel lightheaded or dizzy? 2. Often feel like vomiting or nauseated? F. POSTUE POBES 1. Do you have backaches? 2. Do you have an abnormal curvature of the spine? 3. Are your legs of unequal lengths? 4. Do you have problems sitting still for Prolonged time? 5. Do you cradle the phone between your Head and shoulders? 6. Does your work involve typing/word processing? 7. Do you wear high heels? Seldom Occasionally Frequently G. IFESTYE POBES 1. Are you under a lot of stress? 2. Do you bite your nails, tongue, or lips? 3. Take any mood affecting drugs or stimulants? 4. Do you exercise regularly? 5. Do you usually eat breakfast? 6. Do you work more than 40 hours a week? 7. Do you overeat?
4 TJ QUESTIONNAIE H. JAW (TJ) SYPTOS 1. Have you ever been treated for jaw joint problems, or facial muscle spasms? 2. Do you have difficulty in chewing your food? 3. Do you grind your teeth during the night? 4. Has anyone told you that you grind your teeth? 5. Are you aware of clenching your teeth during the day? 6. Are you aware of clenching your teeth during the night? 7. Are there times when you can t open your mouth widely? 8. Do you have difficulty in opening your outh widely? 9. Does it hurt to open your mouth widely? 10. Does your mouth go to one side when Fully opened? 11. Has your jaw ever locked or were you unable to open or close your mouth 12. Have you had pain in your jaw joint? 13. Do you hear sounds in your jaw joint? 14. Do you hear grating sounds in your jaw joint? 15. Do you hear or feel a clicking or popping in your jaw joint? 16. Does your jaw make clicking or popping sounds when you chew? 17. Does your jaw feel tired after a big meal? 18. Have you experienced numbness of shoulders, arms, hands, or fingers? 19. Do you have pain in your neck and/or shoulders? I. TAUA EATED POBES 1. Accident or trauma to face? 2. Accident or trauma to jaw? 3. Accident or trauma to head? 4. Have you ever received a severe blow to the side of the head or jaw? 5. Accident or trauma to neck? 6. Whiplash or neck injury? 7. Have you worn a cervical traction neck collar? 8. Has there been a strain or stretching of the Jaw while yawning, chewing, or opening the mouth wide? 9. Have you experienced a fall within the last two years? J. Are there any other significant medical or dental problems? III. PACTITIONES Please indicate which practitioners you have seen since your pain began for treatment and relief of pain. Have w Seen Seeing 1. Acupuncturists 2. Allergist 3. Anesthesiologist 4. Cardiologist (heart) 5. Chiropractor 6. Clergyman 7. Dentist 8. Dermatologist (skin) 9. Dietician 10. E.N.T 11. Endocrinologist 12. Faith Healer 13. Family Physician 14. Gynecologist/Obstetrician 15. Hypnotist 16. Internist 17. Naturopath 18. Neurologist 19. Neurosurgeon 20. Nutritionist 21. Ophthalmologist (eyes) 22. Optometrist 23. Orthopedist (bones, joints) 24. Orthodontist 25. Osteopathic physician 26. Pediatrician (children) 27. Physical therapist 28. Physiatrist 29. Plastic Surgeon 30. Proctologist 31. Psychiatrist 32. Psychologist 33. adiologist 34. heumatologist 35. Surgeon 36. Other Other 2 IV. PAIN SUAY Please identify your areas of pain indicating right and/or left that you presently or frequently experience. Presently/and or Frequently 1. Top of head 2. Back of head 3. Frontal headache 4. Eye and eyebrow 5. Temporal headache 6. Jaw and cheek 7. Ear and jaw joint area 8. Toothache 9. Front of neck and throat 10. Side of neck 11. Back of neck 12. Upper thoracic of back 13. id-thoracic of back 14. ower back
5 15. Back of the shoulder 16. Front of shoulder 17. Back of arm 18. Front of arm 19. Upper chest area V. BITE AND TOOTH CONCENS: 1. Bad bite? 2. Buck teeth/overjet? 3. Crowding of upper teeth? 4. Crossbite? 5. Grinding (Bruxism)? 6. Gummy smile? 7. outh too small? 8. Spaces? VI. HEATH POFESSIONA(S): (Current or have seen previously) COENTS: To the best of my knowledge, all the preceding answers are true and correct. If deemed advisable, I grant permission for my physician to be contacted for information and advice. If I have any change in my health or medications that is not reported above, I will inform the doctor at my next visit. I am aware of the $95 initial consultation fee at time of service. Patient s/esponsible Party s Signature Date
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Hi, Sincerely, Nicole R. Patient Treatment Coordinator
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