Patient Adult Information History

Transcription

1 Patient Adult Information History Patient name: Age: Date: What is the main reason for today s evaluation? Infant History Birth delivery: Normal C-section Delayed Epidural Premature: No Yes If yes, how premature Breastfed: No Yes If yes, how long? Bottle fed: No Yes If yes, how long? As a baby, did you have a history of colic? No Yes Pacifier use: No Yes If yes, how long? History of Thumb Sucking? No Yes If yes, to what age? MTHFR Testing? No Yes Speech History Have you had a history of speech therapy? No Yes If yes, when and for what? Orthodontic History Have you had a previous orthodontic evaluation or treatment? No Yes If yes, why were you treated ie, TMD, Cosmetic, Crowding? Or retreats? Did you ever have teeth extracted? Have you ever had headgear, palatal expanders, or any other functional appliances?

2 Medical History Daytime Symptoms: Fatigue Myalgia- Muscle aches, pains, soreness Difficulty concentrating Need a lot of caffeine throughout the day Frequent neck soreness Forgetfulness Do you have difficulty losing weight? No Yes Do you have a problem concentrating at work/school? No Yes Do you worry about things often and have trouble relaxing? No Yes Allergies: No Yes Explain: History of ear infections or tubes: No Yes Explain: Regularly see an allergist or ear, nose, throat specialist: No Yes Breathing: Nasal Mouth Congested Wheezing Medications taken daily? Wear glasses: No Yes Any history of vision issues? No Yes Tonsils/adenoids removal: No Yes Personal History Weight: Height: Neck circumference: Alcohol consumption (drinks per week): Smoking consumption (cigarettes/cigars per week):

3 DO YOU HAVE OR HAVE YOU EVER HAD ANY OF THE FOLLOWING? Y N Y N Y N Depression Nasal Polyps Claustrophobia Chronic Fatigue Syndrome Sinus Migraines History of bed wetting beyond the age of 7? Irritable Bowel Asthma/Hay Fever Heightened gag reflex Syndrome Fibromyalgia Post Nasal Drip Balance issues/tripping Frequent Nose Bleeds History of Deviated Difficulty swallowing pills Septum Mood Swings/Irritability Halitosis (bad breath) Breathe through mouth when eating Anxiety/Panic Attacks Constipation Chewing/Swallowing difficulties Osthostasis- light Tingling in hands Hiccups with regularity headed when standing up Cold Hands/Feet Morning Headaches or Frequent Headaches Chronic cough or throat clearing Frequently sick ie, colds, flus Chapped Lips Family History Have any family members had heart disease/high blood pressure/diabetes? No Yes Do any family members snore; have sleep apnea or a sleep disorder? No Yes Trauma History Any surgeries? Injuries?

4 TMD History Having difficulty with mouth opening: No Yes Have pain or clicking in the jaw joint: No Yes Have pain on chewing, yawning or opening wide: No Yes Have pain in or around the ears and cheeks: No Yes Have a bite that feels uncomfortable or unusual: No Yes Have a jaw that locks or gets stuck: No Yes Have noises in or around the jaw joints: No Yes Any habits: Chewing on pencils Biting nails Lip Biting TMD pain/clicking of joints? No Yes Sleep History Had any of the following: Frequent night awakenings Difficulty initiating sleep Insomnia-difficulty maintaining sleep Nighttime bathroom trips Restless Leg Syndrome Regular Use of Sleep Aids Unexplained shaking at night Night sweats Do you snore or have you been told you snore? No Yes Do you snore only when you are lying on your back? No Yes Do you know if you snore loudly? No Yes Do you know if you snore every night? No Yes Have you been told you stop breathing or gasp during sleep? No Yes Has your partner had to move to another room during the night? No Yes Do you have difficulty falling asleep? No Yes Do you wake up with a dry mouth? No Yes Do you or have you been treated for high blood pressure? No Yes Do you have GERD or reflux? No Yes Do you feel sleepy and struggle to remain alert during the day? No Yes

5 Do you often wake feeling tired? No Yes Do you often feel sad or depressed because you can t sleep? No Yes Do you have a nasal congestion? No Yes Do you grind or clench your teeth in your sleep? No Yes Have you had motor vehicle accidents or near misses while driving? No Yes Are you sleepy while driving? No Yes Have you ever been diagnosed with sleep apnea? No Yes Have you ever been seen by a specialist for snoring/sleep apnea? No Yes Have you ever had a sleep study? No Yes If yes, when and where? Have you ever been treated for snoring/sleep apnea/sleep disorder? No Yes Epworth Sleepiness Scale The Epworth Sleepiness Scale is used to determine the level of daytime sleepiness. Depending upon your score, we may discuss whether you are obtaining adequate sleep, need to improve your sleep hygiene and/or need to an additional evaluation by a sleep specialist. How likely are you to fall asleep in the following situations? Sitting and reading Watching TV Sitting inactive in a public place As a passenger in a car longer than 1 hour Lying down in the afternoon Sitting and talking to someone Sitting quietly after lunch (no alcohol) In a car stopped in traffic for a few minutes Would never doze 0 Slight chance of dozing 1 Moderate chance of dozing 2 High chance of dozing 3 Score Snoring and Obstructive Sleep Apnea (OSA) are breathing disorders, which occur during sleep, due to the narrowing or total closure of the airway. Snoring is a noise created by the partial closure of the airway and is often no greater problem than the noise itself. However, consistent loud snoring with OSA symptoms has been linked to medical disorders such as hypertension (high blood pressure) and stroke.

6 Obstructive Sleep Apnea occurs when the airway totally closes many times during the night. It can significantly reduce oxygen levels in the body and disrupt sleep. To varying degrees, this can result in excessive daytime sleepiness, irregular heartbeat, hypertension, and occasionally heart attack and stroke. Signed: Date: