Patient Health Questionnaire PATIENT INFORMATION Date of completion O MNDX TM OMr. 0Ms. 0Miss 0Mrs. []Dr. First Middle Initial Age: Date of Birth: Referred by: ODDS DMD DENT ODC 00ther 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: 0Pain D Sleep/Airway D Orthodontics 0Unknown WHATISTHECHIEFCOMPLAINTFORWHICHYOUARESEEKINGTREATMENTINOUROFFICE? 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 _Kicking or jerking leg repeatedly _ Jaw pain _Swelling in ankles or feet _ Pain when chewing _ Morning Hoarseness _ Facial pain _Dry mouth upon waking _ Eye pain _Fatigue _ Throat pain _Difficulty falling asleep _ Neck pain _Tossing and turning frequently _ Shoulder pain _Repeated awakening _ Back pain _Feeling unrefreshed in the morning Limited ability to open mouth _ Significant daytime drowsiness _ Jaw joint locking _Frequent heavy snoring _ Jaw joint noises _Affects sleep of others Ear congestion _ Gasping when waking _ Sinus congestion _Told that "I stop breathing" during sleep Dizziness Night-time choking spells _ Tinnitus (ringing in the ears) Unable to tolerate C-Pap _ Muscle twitching _Tooth grinding _ Vision problems _Teeth crowding _ O ther: ------------------------------ D Do you have concerns in any of these areas: D D General Appearance Ability to Function Last D Overbite D Smile D Do any of the above complaints or concerns affect your daily life? WHAT ARE THE RESULTS YOU ARE SEEKING FROM TREATMENT? Patient Signature:----------------- 1 Date: ------------
ALLERGIC REACTIONS Please check any and all me Anesthetics ations or substances that have caused an allerf;ic reaction Codeine Peniciffin Antibiotics eiodine Plastic Aspirin Latex Sedatives Barbituates Metals 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. Meoication Dosage Reason for Talcing - -- D See attached list PREVIOUS TREATMENTS/MEDICATIONS FOR THE CONDITION WE ARE EVALUATING. _ T... r..,e=at=m=ent... an=d/-=-o'-r M=edi = =ca=tt= o=n -'D"" 'o"'c-'--' to... r/... P=ro.,.v=id=er"""N"'-=am=e'--...,Approximate Date oftreatlnent I release and give my permission for this office to request information and communicate with the providers listed above. Patient Signature: ------------------------------------------ Date:---------------------------------------- Date: Parent/Guardian Signature (if patient is a minor):-------------------------------------------- HEAL TH AND MEDICAL HISTORY Are you currently pregnant? Have you sustained injury to: 0Head Do you drink 4 or more cups of coffee per day? Have you had prior orthodontic treatments? Trouble breathing through nose 0Neck 0Face 0Teeth D0ther: D Yes D No Do you smoke tobacco? D Yes D No Consume alcohol or take sedatives Patient Signature : ----------------------------------------------------------------- Date:-------- 2
HEAL TH AND MEDICAL HISTORY (CONTINUED) Do you have, or have you experienced any of the following: Yes No Heart Disorder/ Heart Attack Yes No Thyroid Problem Yes No Heart Murmur Yes No Tuberculosis Yes No Mitral Valve prolaps Yes No Intestinal Disorder Yes No Heart Pacemaker Yes No Nervous System Disorder Yes No Heart Palpitations Yes No Anxiety Yes No Heart Valve Replacement Yes No Skin Disorder Yes No Irregular Heartbeat Yes No Urinary Tract Disorder Yes No Blood Pressure.D_High.0.Low Yes No Chronic Fatigue Yes No Stroke Yes No Fibromyalgia Yes No Bleeding Easily Yes No Cold hands and feet Yes No Bruising Easily Yes No Depression Yes No Cancer of Yes No Difficulty concentrating Chemo _Il_ Radiation _il_ Yes No Difficulty breathing at night for sleep N, Anemia Yes No Dizziness Yes No Asthma Yes No Excessive Thirst Yes No Birth Defects Yes No Fainting Yes No Diabetes Yes No Fluid Retention Yes No Epilepsy Yes No Frequent colds/flu Yes No Emphysema Yes No Frequent cough Yes No Glaucoma Yes No Frequent ear infections Yes No Gastroesophpgeal Reflex (Gerd) Yes No Frequent sore tbroat Yes No Hemophilia Yes No Frequent awaking at night - number of times Yes No Hepatitis Yes No Hearing impairment Yes No History of Substance Abuse Yes No Memory Loss Yes No Hypoglycemia Yes No Hay Fever Yes No Huntington's Disease Yes No Insomnia Yes No Kidney Disease Yes No Muscle aches Yes No Liver Disease Yes No Muscle fatigue Yes No Leukemia Yes No Muscle spasms Yes No Migraines Yes No Muscle tremors Yes No Meniere's Disease Yes No Poor circulation Yes No Multiple Sclerosis Yes No Psychiatric Care Yes No Muscular Dystrophy Yes No Recent weight gain Yes No Neuralgia Yes No Recent weight loss Yes No Osteoartbritis Yes No Sinus problems N, Osteoporosis Yes No Shortness of breath [ Yes No Ovarian Cyst Yes No Slow healing sores Yes No Parkinson's Disease Yes No Speech difficulties Yes No Rheumatic Fever Yes No Swollen, stiff or painful joints Yes No Rheumatoid Arthritis 0No Tired muscles 0No Scarlet Fever Additional Information SURGICAL HISTORY Have you had any of the following: Yes No Yes No Adenoids removed D No Oral Surgery General Anesthesia D Yes D No Orthognathic Surgery Yes No Tonsils removed Removal of third molar (wisdom teeth) _.D_ Other _D_ D No Other types of surgery Jaw Joint Surgery D No Other surgery please list below 3 Date:
CURRENT SYMPTOMS Head Pain Location Recent Chronic Severity Duration Frequency L = Left R = Right B = Bilateral (over6mo.) Mild Mod Severe Min. Hrs. Days Occasional Frequent Constant 1[){]B[] Frontal (Forehead) D D D D D D D D D D D 1[){]B[] Generalized D D D D D D D D D D D 1[){]B[] Parietal (Top of head) D D D D D D D D D D D r.[){]s[ Occipital (Back of head) D D D D D D D D D D D r.[){]s[ Temporal (Temple area) D D D D D D D D D D D Jaw Pain Jaw Locking Do you have pain or discomfort in any of the following areas? If so, please indicate the approximate date the pain began. L R Jaw pain with opening L R Jaw pain when chewing L R Jaw pain at rest DYesDNo DYesDNo Jaw locks closed Jaw locks open Jaw Joint Sounds Jaw sounds with opening Jaw sounds when chewing Jaw sounds at rest Jaw Joint Symptoms DY es Do Teeth clenching DDay DNight DY es Do Teeth grinding DDay DNight Eye Related Conditions yes No Blurred vision Yes No Double vision Yes No Eye pain 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 Throat Related Conditions yes No Chronic sore throat Yes No Difficulty swallowing Yes No Swollen glands Neck Related Conditions DY es DNo Limited movement of neck DY es DNo Neck pain aes No Pain or pressure behind the eyes es No Extreme sensitivity to light (photophobia) es No Wear of glasses or contact lenses Pain behind the ear Pain in front of the ear Recurrent ear infections Ringing in the ear (Tinnitus) Yes No Thyroid enlargement Yes No Tightness in throat Yes No Constant feeling of a foreign object in throat D Y es D No Numbness in hands or fingers DY es D No Swelling in the neck 4
Shoulder Related Conditions DY es DNo Shoulder pain DY es DNo Shoulder stiflhess Back Related Conditions es No Back pain - lower es No Back pain - middle es No Back pain - upper Mouth and Nose Related Conditions es No Dry mouth es No Chronic sinusitis es No Frequent snoring DY es DNo Tingling in hands or fingers DY es DNo Sciatica DY es DNo Scoliosis Yes No Burning tongue Yes No Broken teeth Yes 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 Dside DBack Dstomach []varies Average hours ofsleep per night? Is it easy to fall asleep? es No Do you wake often during the night? Do you feel rested upon AM waking? es No Gasping or Choking during sleep? Yes No Yes No Stopped breathing during sleep? es 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? DY es DNo 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 insurance coverage. Patient Signature: ---------------------------------------------------------------------------- Date: Parent/Guardian Signature (if patient is a minor)=----------------------------------------------------- Date: ------------------------ 5
Left Right Left Indicate Areas of Pain Following the Pain Scale: 1 Mild pain 2 Moderate pain 3 Severe pain