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Reason for this Visit (Hold Ctrl Key to choose multiple)
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Reason for this Appointment - Other
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Top 3 Complaints (Hold Ctrl Key to choose multiple)
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Tell us your Medical Story
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When did your condition begin?
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When did your condition begin - Other?
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What is the cause of your pain or condition?
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Cause of your pain or condition - Other?
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What makes your pain or discomfort worse?
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What makes your pain and discomfort better?
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Have you had prior Orthodontic Treatment?
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Are you currently Pregnant?
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Are you currently breastfeeding?
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Have you had your wisdom teeth removed?
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Have you had dental treatement for your pain?
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Have you had Jaw Joint surgery?
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Have you had Orthognathic Surgery?
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Please list other surgeries:
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Allergy History (Check All That Apply)
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ENT History
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Cancer History
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Eye History
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Pulmonary History
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Infectious Disease
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Cardiac History
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Gastrointestinal History
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Truama
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Hematological History
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Kidney/Bladder History
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Neurological History
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Musculoskeletal History
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Endocrine History
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Systemic Symtoms (Click all that apply)
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Otolaryngial Symptoms
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Head symptoms
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Musculoskeletal symptom
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Neurological symptoms
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Neck symptoms
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Cardiovascular
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Gastrointestinal
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Endocrine
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Psychological Symptoms
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Skin symptoms
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Other Symtoms:
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Do you have "Generalized" Headaches?
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If "YES" Above, For How Long?
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Headache Severity?
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Headache Location?
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Frequency of your Headaches?
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Duration of Headache?
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Do you have Headaches on the "Forehead"?
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If "YES" Above, For How Long?
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Headache Severity?
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Headache Location?
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Frequency of your Headaches?
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Duration of Headache?
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Do you have Headaches on the "Top of the Head"?
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If "YES" Above, For How Long?
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Headache Severity?
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Headache Location?
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Frequency of your Headaches?
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Duration of Headache?
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Do you have Headaches in the "Back of the Head"?
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If "YES" Above, For How Long?
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Headache Severity?
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Headache Location?
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Frequency of your Headaches?
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Duration of Headache?
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Do you have Headaches in your "Temple Area"?
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If "YES" Above, For How Long?
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Headache Severity?
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Headache Location?
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Frequency of your Headaches?
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Duration of Headache?
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Do you have Jaw Pain?
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Do you have Jaw Locking?
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Do you have Jaw Joint Sounds?
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Any eye related conditions?
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What are your Jaw Joint Symtoms?
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Any Mouth or Nose Relationed Conditrions?
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Any ear related conditions?
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What positions do you sleep in?
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Do you feel rested upon waking in the morning?
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Is it easy to fall asleep?
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Average hours of sleep per night?
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Have you ever stopped breathing during sleep?
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Do you recall Gasping or Choking during sleep?
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Do you wake often during the night?
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(if YES to Sleep Study) What was the result?
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Have you had a Sleep Study (PSG) within 3-years?
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Family History
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Social History
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What is your occupation?
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