COMPREHENSIVE HEALTH QUESTIONNAIRE

COMPREHENSIVE HEALTH QUESTIONNAIRE
The purpose of this questionnaire is to determine the nature of your health problem. It is very important to be as accurate as possible in answering the questions. Your partner may be able to assist you.

*Please remember to write your name at the top of each page.

General Information (This information will become part of your medical record and will remain confidential
Patient Name:*
Patient Name:*
Patient Name:*
Date:

MonthDayYear
Date
Address:
Address:
Address:
Address:
Home Phone
Work Phone:
Cell Phone:
May we call you at work?
Email:
example@example.com
Best way to reach you?
Date of Birth:*

MonthDayYear
Date
Age:
Sex:

MaleFemale
Height:
Weight:
Marital Status:

SingleWidowed
Marital Status:

DivorcedMarried/Partner
SSN:
Occupation:
Emergency Contact:*
Phone Number:
Phone Number:*
Referring Physician:
Primary Care Physician:
List current medical conditions for which you are being treated.
Diagnosis
List all hospitalizations and surgeries you have had. (Please be thorough and include surgeries to remove your adenoids or

tonsils, or hospitalizations for head injury, seizures or heart conditions
Diagnosis
List medications you are currently taking. (Please include prescription and non-prescription medications of all types, including

sleep and non-sleep related. Also indicate if you are on supplemental oxygen
Medication
Please list any allergies we should be aware of:
Patient Name:*
DOB:*
DOS:
DOS:

YesNoYesNo
Health Questions (Please answer the best you can)

Are you unable to sleep in a flat position due to shortness of breath?

Do you have a family history of snoring or other sleep disorders?
Have you ever sustained a brain concussion, head injury or serious blow to the head?

YesNoYesNoYesNoYesNoYesNo
Do you have spells or seizures?

Do you have high blood pressure?

Have you experienced a weight gain in the last year?

Has your shirt collar size increase recently?
Do you smoke?

YesNo
How many packs per day?
How long have you smoked?
Have you quit smoking?
How many packs per day prior to quitting?
How long did you smoked?
Year quit?

Yes
Year quit?
Year quit?

NoYesNo
Year quit?

YesYesNoNo
If yes, please estimate the number of drinks per day. (beer, wine, or liquor)
Do you drink caffeinated drinks?
If yes, please estimate the number of drinks per day. (sodas, coffee, or tea)
(Female) Have you gone through menopause?

(Males) Have you experience any prostate issues? (i.e. Frequent urination)
Sleep Health Concerns & Habits
Describe your sleep problem(s) in your own words.
Describe how and when this problem began.
Describe any treatments you have received for your problem.
Has this been a continuous problem?
and goes

ComesOccasionalFrequentConstantGreater1-2 yrs.SeveralLast 3Within the
How long has your sleep problem bothered you?
What time do you usually go to bed?
Week Days:
Weekends:
What time do you usually wake up?
Week Days:
Weekends:
How many hours of sleep do you usually get per night?
How long does it take you to fall asleep?
If you awake in the middle of the night, how long are you typically awake for?
Which shift do you work? (Check all that apply)

Sleep Questions

	Never	Rarely	Often	Frequent	Always
How often do you rotate shifts?
Does your job require overnight travel?
Do you drink alcohol at 6pm?
Do you drink caffeinated beverages after 6pm?
Do you suffer from a loss of libido?
(Males) Have you experienced difficulties with sexual 17 functions?

Never

DayEveningNight
Patient Name:*
DOB:*
DOS:

Sleep Questions

	Rarely	Often	Frequent	Always
(Females) Does your sleep problem vary according to
(Females) Have you gone through menopause or had a
Are you able to fall asleep and awaken on a daily,
Do you nap during the day or evening?
Do you feel refreshed after a typical night’s sleep?
Do you feel sleepy during the day even when you have
Do you feel refreshed after a short nap?
Do you get sleepy while driving?
Have you had an accident or near-accident when
(movies, theater, church, or watching television)?
Are you able to fight off the excessive sleepiness?
Do you have memory or concentration problems?
Do you experience vivid dream-like scenes upon
When you are angry or laugh, do you ever feel weak, as
Are you ever unable to move or speak upon falling
Do you have trouble falling asleep when you go to bed?
When you try to fall asleep does your mind race with
When you try to fall asleep do you feel pain?
Does pain ever wake you up, disrupt your sleep or keep
Are you a light sleeper, easily awakened?
Is your sleep disrupted because of your bed partner or

Does your breathing sometimes stop during sleep?

Neverhysterectomy?weekly basis according to your desired schedule?the stage of your menstrual cycle?DOB:slept all night?Sleep QuestionsPatient Name:driving, due to excessive sleepiness?Do you fall asleep when you want to stay awakeDOS:Form 5awakening or falling asleep?though you might fall?asleep or awakening?Do you have trouble falling asleep when you go to bed?thoughts?When you try to fall asleep do you feel pain?you from going back to sleep?others in your household?Are you a light sleeper, easily awakened?Do you snore?Does your snoring stop for brief periods during sleep?

legs when you lie down to sleep?

	-	-	-	-

Does your breathing sometimes stop during sleep?
Is your bed partner disturbed by your snoring?
Do you wake up choking or gasping for breath?
Do you have night sweats?
Do you have heartburn at night?
Do you have a bitter bile taste in the back of your
throat when you wake up (not “morning breath”)?
Do you have nasal / sinus congestion at night?
Do you have morning headaches?
Are you a restless sleeper, tossing and turning at night?
Do you have a creeping or crawling sensation in your

Do you experience any type of leg or back pain during 18 the night?

Does your breathing sometimes stop during sleep?Is your bed partner disturbed by your snoring?Do you wake up choking or gasping for breath?Do you have night sweats?Do you have heartburn at night?Do you have a bitter bile taste in the back of yourDo you have nasal / sinus congestion at night?Do you have morning headaches?Are you a restless sleeper, tossing and turning at night?legs when you lie down to sleep?
Do you experience any type of leg or back pain during 18 the night?

Do you experience any type of leg or back pain during 18 the night?Do you experience any type of leg or back pain during 18 the night?Do you experience any type of leg or back pain during 18 the night?Do you experience any type of leg or back pain during 18 the night?Do you experience any type of leg or back pain during 18 the night?

Patient Name:

	-	DOB:	-
Do you wake up with sore or aching muscles or joints
Do you grind or clench your teeth during sleep?
Did you walk or talk in your sleep as a child or
Do you now walk or talk in your sleep?
Do you have frightening dreams or nightmares?
Do your dreams or nightmares awaken you?
Do you wet your bed?

Patient Name:*
Patient Name:

DOS:Form 5
DOB:*
DOS:

(including leg or back pain)?

	-	-	-	-	-

adolescent?



Other Sleep Concerns:

Temporomandibular Joint Disorder (TMJ/TMD) & Pain Concerns
Temporomandibular Joint Disorder (TMJ/TMD) & Pain Concerns
Symptom Questions

Do you have pain in the jaw joint?Do you have pain around the eyes?Do you have pain in the ear?Left SideSubjective hearing lossTemporomandibular Joint Disorder (TMJ/TMD) & Pain ConcernsDo your symptoms affect one or both jawYesNo
Left Side

Right SidePain in foreheadRight SideLeft SidePain in facial areaGrating sound in joint
joints?

cervical traction?Pain in shoulderNoPatient Name:Ringing sound in earsFullness, pressureYesblockage in earNoYesNo
joints?

Pain in lower jawYesNoPain in upper jawDo you have arthritis?YesSymptom QuestionsPain in neckHave you ever hadNoYes
Do you have arthritis?

Dizziness (vertigo)Upset stomach- nausea
Total inability to open mouth

Other Pain QuestionsPain in tongueHeadache
Circle the kind of pain you have:

Does the pain last for a moment
What time of the day or night is the pain the most severe

SharpConstantDullIntermittentSuperficialSpreadingAchingPulsating ⬜ BurningDeepMinutesHoursGraduallyAll dayGradually
What time of the day or night is the pain the most severe
How often do you have pain?
What is the longest period you have gone without pain?
What medication(s), if any, do you take to relieve the pain?
Does rest increase or decrease the pain?
Please describe any method of positioning the jaw or head that you have found for relieving pain:
Do any of the following normal daily activities cause pain? If yes, indicate where you feel pain.
Do any of the following normal daily activities cause pain? If yes, indicate where you feel pain.

YawningSwallowingBrushingMoving shouldersChewingSpeakingSingingShoutingMoving neckMoving headMoving armsMoving trunk
Patient Name:
DOB:*
DOS:
DYSFUNCTION
Can you open your mouth normally?

Do you ever open so wide your mouth locks open?
Yes

CompletelyPartiallySnappingGrating
Do you have any of these sounds in the joint?

If you have any of these problems is it frequent?

Have you noticed any change in your bite?
MISCELLANEOUS AND ASSOCIATED COMPLAINTS AND QUESTIONS

YesNoYesNoYesNo
Are your jaw muscles ever tired?
Do you have a jaw thrust habit or nervous twitch about the face?

YesYesNoNoYesNoYesNoYesYesNoSevere emotional upset ⬜ A blow on the jaw ⬜ Excessively large bite or yawnNoTraction for cervical whiplash ⬜ Traction for cervical arthritisDid the symptoms start after any of the following conditions?How long have you been bothered by this problem?MISCELLANEOUS AND ASSOCIATED COMPLAINTS AND QUESTIONSYesNoYesYesNoNoYesNoYesYesNoNo
Have you ever noticed production of more saliva or less saliva?

Do tears form in your eyes for no apparent reason?

Have you had any injury to the jaw or face? If yes, explain.
Have you had your teeth straightened (orthodontia)?

Do you chew gum? Frequently Moderately Infrequently NeverHas anyone mentioned that you grind your teeth (brux) at night during sleep?Is there anyone else in your family with a similar problem? (If yes, explain)By whom?Have you had any other treatment for this problem? (If yes, explain-medicine, exercise, dental treatment)
Are you sensitive to metal rings or earrings?

Have you had your bit adjusted by your dentist? (If yes, please explain when)

Do you attribute the symptoms to any one incident?

Have you had cortisone injected into the joint? If yes, when?

Do you know if you clench your teeth?
Do you chew gum? Frequently Moderately Infrequently Never

YesYesNoNo
Please describe briefly any changes in location or character of symptoms since this problem began
Please list chronologically names and types of doctors and their locations, whom you have seen in the past for this or related
problems. Write on the back of the sheet if necessary
Did any of the treatments make you feel better? If so, which helped the most? In what manner?
Did any of the treatments make you feel worse? Which ones? In what manner?
Please write in any other pertinent information that has not been covered previously.
Should be Empty:

COMPREHENSIVE HEALTH QUESTIONNAIRE

Sleep Health Concerns & Habits

DYSFUNCTION