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General Medical History
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Do you have or have you had any of the following?
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Rhuematologic Disorder
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Autonomic Nervous System
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Cardiovascular
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Endocrinology
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Extremities
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Functional Somatic Syndrome (Behavior/ Psycho/ Social)
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Gastroenterology
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Hematology
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HEENT
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Immunology/Allergy
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Immunology/Allergy
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Infectious Disease
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Neurologic
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Nutrition
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Oncology
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Pulmonology
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Renal
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Skin
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Pregnancy/Nursing
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Past Surgical/Hospitalization History - Include Date with Surgeon Name
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If you have never had any surgeries, please turn on this switch
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5.
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If you have problem with Anesthetic, please explain
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I you ever spent one night in the hospital please include reason and date's.
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Are you currently taking any blood thinners or anti-coagulants?
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If yes, please list the name(s)
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Pain Disorders
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Pain Disorders
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Other Pain Disorders
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Have you ever used an occlusal guard/night guard?
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TMJ or Facial Pain?
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TMJ or Facial Pain Scale
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TMJ or Facial Pain Frequency
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How have you managed your pain?
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Other Pain Management?
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Headaches
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Have you ever used an occlusal guard/night guard?
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TMJ or Facial Pain - Headaches?
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TMJ or Facial Pain Scale
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TMJ or Facial Pain Frequency
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How have you managed your pain?
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Other Pain Management?
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Allergies
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Please turn on this switch, if you do not have any allergic reactions
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List medications, foods, and environmental elements that you are allergic to
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Type of allergy
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Other please specify
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Family History - Mark all appropriate diagnoses as they pertain to your first-degree relatives
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Other Family Medical Problems - Please Specify
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Prenatal History
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Prenatal History
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Other Prenatal History
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Birth History
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Birth History
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Early Feeding History
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Early Feeding History
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Other Early Feeding History
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Breastfed Duration
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Early Feeding Skills
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Early Feeding Skills
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Diagnosed Feeding Disorder? (Describe)
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Fine Motor Development
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Fine Motor Development
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Gross Motor Development
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Gross Motor Development
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Reported Food Aversions
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Reported Food Aversions
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Other Food Aversions
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Special Diet Considerations
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Special Diet Considerations
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Other Dietary Considerations
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Generalized Complaints
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Generalized Complaints
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Reported Chewing Patterns
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Reported Chewing Patterns
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Other Reported Chewing Patterns
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Pill Swallows
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Large Pill Swallows
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Small Pill Swallows
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Sensitivities
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Sensitivities
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Sleep Quality Considerations
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Do You Snore?
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Average Hours of Sleep Per Night
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Do you wake up refreshed?
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Do you wake up w/ chronic fatigue or feelings of constantly being tired?
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Have you been tested for Sleep Apnea?
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If yes, what was your diagnosis?
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Do you use a CPAP or Dental Sleep Appliance
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If yes, indicate the type.
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CPAP/Dental Appliance Use
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