Hi, Sincerely, Nicole R. Patient Treatment Coordinator
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- Frederica Wilkinson
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1 Hi, I just wanted to send you this short letter to thank you, and to congratulate you for choosing Dr. Klauer at the TMJ & Sleep Therapy Centre. We so look forward to getting to know you, and we have such exciting plans for your upcoming visit. The TMJ & Sleep Therapy Centre team is made up of highly dedicated and exceptionally skilled individuals. You'll find that every single person here is committed to helping you get the very best outcome, and to helping you discover your most effective path to pain relief and healthful sleep. Dr. Klauer is a recognized leader in craniofacial pain, sleep apnea, dental sleep medicine, orthodontics, and orthopedic function. Having completed over 1,500 hours of continuing education, he is a sought-after speaking and renowned specialist, educating dentists and healthcare professionals around the world in smart, sustainable pain relief and sleep health. I have personally seen Dr. Klauer not only help patients, but literally transform lives. Freedom from pain and the ability to enjoy a full, uninterrupted nights sleep is no small thing, and the results that Dr. Klauer achieves every single day truly elevate the lives of each individual who comes through the door here. Often, Dr. Klauer's patients have suffered with pain or sleeping issues for years - sometimes even decades - and being on hand to see these individuals find the joy and energy that renewed health provides is something wonderful. We are so ecstatic that you've taken this first incredible step. You are going to be amazed by the results, that I can promise you. Included in this is your official TMJ & Sleep Therapy Centre medical intake form. Please take a few minutes to complete this to the best of your ability. We would also like to invite you to visit our website Here you will be able to view our patient testimonials as well as meet Dr. Klauer and our amazing team. And of course, don't hesitate to , call, or stop by to chat with any questions you may have. We are so excited to hear from you and to welcome you to the family! Remember, our holistic, sustainable approach to your well-being means we never settle for a quick fix; here, you'll get long-term solutions that make your life more relaxed, rewarding, and fun. We are very much looking forward to your upcoming visit. Please return your patient health questionnaire 24 hours prior to your appointment. Once again, feel free to contact me any time with your thoughts or questions. It will be my pleasure to assist you in every possible way. Sincerely, Nicole R. Patient Treatment Coordinator
2 Date of completion: Patient Health Questionnaire Name: Single Married Widowed Separated Divorced Age: Date of Birth: SSN: Sex: Male Female Race: Ethnicity: Hispanic/Latino Not Hispanic/Latino Patient Address: City: State: Zip: Home Phone: Family Dentist: Referred by: Alternative Phone: Employer Name: Family Doctor: Other Doctors: Reason(s) for this appointment: Pain Sleep/Airway Orthodontics Primary Medical Insurance Person Responsible for Account: Relation to Patient: Date of Birth: SSN: Responsible Party Employer: Insurance Company: Contract #: Group #: Provider #: Additional Insurance Is the patient covered by any additional insurance? Person Responsible for Account: Relation to Patient: Date of Birth: SSN: Responsible Party Employer: Insurance Company: Contract #: Group #: Provider #: Page 2 of
3 What are the chief complaints for which you are seeking treatment in our office? *Please identify your chief complaint as 1 and number all other complaints starting at 2 and going up. Back pain Neck Pain Gasping Upon Waking Difficulty Closing Mouth Nerve Pain Kicking or Jerking Leg Repeatedly Difficulty Opening Mouth Numbness Morning Headaches Dizziness Pain When Chewing Morning Hoarsness in Voice Dyskinesia Shoulder Pain Night Sweats Ear Congestion Sinus Congestion Nighttime Choking Spells Ear Pain Throat Pain Nighttime Urination Ear Stuffiness Tinnitus (Ringing in Ears) Repeated Awakening Eye Pain Vision Problems Short of Breath Facial Pain Acid Indigestion Sore Jaw Upon Waking Headache (inside head) Affecting Sleep Partner Swelling in Ankles/Feet Headache (outside head) Difficulty Falling Asleep Teeth Crowding Jaw Joint Locking Dry Mouth Upon Waking Teeth Grinding Jaw Joint Noises Fatigue Told I Stop Breathing During Sleep Jaw Pain Feel Unrefreshed in the Morning Unable to Tolerate CPAP Limited Ability to Open Frequent Heavy Snoring Vivid Dream Muscle Twitching Frequent Tossing & Turning What are the results you are seeking from treatment? Allergic Reactions: Please check any and all medications or substances that have caused an allergic reaction. Other: Anesthetics Barbituates Latex Plastic Antibiotics Codeine Metals Sedatives Aspirin Iodine Penicillin Sulfa Current Medications: Please list all medications you are currently taking and the reason you are taking them. Include prescription, over-the-counter, vitamins, herbs, etc. Medication Dosage Reason for Taking Previous treatments/medications for the condition we are evaluating: Treatment/Medication Doctor/Provider Approximate Date of Treatment Surgical History: Please indicate if you have had any of the following. Others: General Anesthesia Tonsils Removed Orthognathic Surgery Removal of Wisdom Adenoids Removed Jaw Joint Surgery Oral Surgery Teeth Page 3 of
4 Health & Medical History: Have you ever had a sleep study? Are you currently pregnant? Have you sustained injury to: Do you drink 4 or more cups of coffee per day? Do you have trouble breathing through your nose? Head Neck Face Teeth Other Do you smoke tobacco? Do you have or have you experienced any of the following? Anemia Heart Disorder/Heart Attack Osteoarthritis Anxiety Heart Murmur Osteoporosis Asthma Heart Pacemaker Ovarian Cyst Birth Defects Heart Palpations Parkinson's Disease Bleeding Easily Heart Valve Replacement Poor Circulation Bruising Easily Hemophilia Psychiatric Care Cancer Hepatitis Recent Weight Gain Chronic Fatigue High Blood Pressure Recent Weight Loss Cold Hands and Feet History of Substance Abuse Rheumatoid Arthritis Depression Huntington's Disease Rheumatoid Fever Diabetes Hypoglycemia Scarlet Fever Difficulty Breathing at Night Insomnia Shortness of Breath Difficulty Concentration Intestinal Disorder Significant Daytime Drowsiness Dizziness Irregular Heartbeat Sinus Problems Emphysema Kidney Disease Skin Disorder Epilepsy Leukemia Slow Healing Sores Excessive Thirst Liver Disease Speech Difficulties Fainting Low Blood Pressure Stroke Fibromyalgia Memory Loss Swollen, Stiff, or Painful Joints Fluid Retention Meniere's Disease Thyroid Problem Frequent Awakening at Night Migraines Tired Muscles Frequent Colds/Flus Mitral Valve Prolap Tuberculosis Frequent Cough Muscle Aches Urinary Tract Disorder Frequent Ear Infections Muscle Dystrophy Frequent Sore Throat Muscle Fatique Gastroesophageal Reflex (Gerd) Muscle Spasms Other: Glaucoma Muscle Tremors Hay Fever Multiple Sclerosis _ Hearing Impairment Nervous System Disorder Neuralgia Patient Signature: Parent/Guardian Signature: Date: Page 4 of
5 Current Symptoms Head Pain Location Recent Chronic Severity Duration Frequency L=Left, R=Right, B= Bilateral (over 6 mo.) Mild Moderate Severe Min. Hrs. Days Occasional Frequent Constant L R B Temporal (Temple area) L R B Occipital (Back of head) L R B Frontal (Forehead) L R B Parietal (Top of head) L R B General Do you have pain or discomfort in any of the following areas? Jaw Pain L R Jaw pain with opening L R Jaw pain when chewing L R Jaw pain at rest Jaw Joint Sounds L R Jaw sounds with opening L R Jaw sounds when chewing L R Jaw sounds at rest Jaw Locking Jaw locks closed Jaw locks open Jaw Joint Symptoms Teeth clenching or grinding Yes? Day Night Eye Related Conditions Blurred vision Double vision Eye pain Pain or pressure behind the eyes Extreme sensitivity to light Wear glasses or contact lenses Ear Related Conditions L R Buzzing in the ears L R Ear congestion L R Ear pain 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 Throat Related Conditions Chronic sore throat Difficulty swallowing Swollen glands Thyroid enlargement Tightness in throat Constant feeling of a foreign object in throat Neck Related Conditions Limited movement of neck Neck pain Numbness in hands or fingers Swelling in the neck Shoulder Related Conditions Shoulder pain Shoulder stiffness Tingling in hands or fingers Back Related Conditions Back pain lower Back pain middle Back pain upper Sciatica Scoliosis Mouth and Nose Related Conditions Dry mouth Chronic sinusitis Frequent snoring Burning tongue Broken teeth Frequent biting of the cheek History of Symptoms On what date, or approximate date, did your condition or symptoms first occur? Can you relate your pain or condition to a motor vehicle accident or traumatic injury? If yes, please explain: Do any family members have a sleep disordered breathing problem? If yes, please explain: Page 1 of 1
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CASE NO. Please fill out the following form in as much detail as possible. Please Print Date Name Address City State Zip Home Phone Office Phone E-mail Address Age Date of Birth Occupation Sex (M) (F)
Medical and Dental Health History Form Getting to Know You As Our Patient
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PLAS/RECON SURGERY PATIENT HEALTH HISTORY
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PULMONARY MEDICINE PATIENT QUESTIONNAIRE
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LECOM Health Ophthalmology
Patient Name: Date of Birth: New Patient Questionnaire Your answers will be used by your healthcare provider get an accurate history of your medical conditions and ocular concerns. If you are uncomfortable
Personal &Work Information Date: Patient Name: Age: City: State: Zip: Primary Care Physician: PCP Phone:
Personal &Work Information Date: Patient Name: Age: Birth Date: / / Preferred Name: Gender: Home Phone: Address: Mobile Phone: City: State: Zip: Occupation: Employer: Work Phone: Email: Emergency Contact:
NEW PATIENT INFORMATION
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Medical History Form
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New Patient Documentation. Name: (Last) (First) (Middle) Address: (Street) (Apt#) (City) (State) (Zip) Home Phone: ( ) Cell: ( ) Work: ( )
New Patient Documentation Name: (Last) (First) (Middle) Address: (Street) (Apt#) (City) (State) (Zip) Home Phone: ( ) Cell: ( ) Work: ( ) Age: Birthdate: E Email: Social: Sex: Male Female Height: Weight:
* CC* PATIENT QUESTIONNAIRE
Pain Center of Michigan *0290341CC* PATIENT QUESTIONNAIRE Patient Name Birthdate Age Home Address City State Zip Home Phone Alternate Phone Referring Physician Primary Care Physician MEDICAL HISTORY Please
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PH NEW PATIENT HISTORY Patient Name Date of Birth MALE / FEMALE Date Occupation: Left handed or Right handed Marital Status: Single Married Divorced Widowed Children? Y or N # Previous Treating Physician:
Fairfax Oral and Maxillofacial Surgery
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DATE OF BIRTH: MELANOMA INTAKE
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