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.
General Information
(This information will become part of your medical record and will remain confidential.)
Patient Name
*
First Name
Middle Name
Last Name
Date
/
Month
/
Day
Year
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone Number
*
Please enter a valid phone number.
Cell Phone Number
*
Please enter a valid phone number.
Work Phone Number
*
Please enter a valid phone number.
May we call you at work?
Yes
Email
*
example@example.com
Best way to reach you
Please Select
Home Phone
Cell Phone
Work Phone
Email
Date of Birth
*
-
Month
-
Day
Year
Date
Age
Height
Weight
Sex
Male
Female
Type a question
Single
Widowed
Divorced
Married/Partner
SSN
Occupation
Patient Signature
*
Clear
Emergency Contact
First Name
Middle Name
Last Name
Relationship
Your relationship with the emergency contact.
Phone Number
Please enter a valid phone number.
List current medical conditions for which you are being treated
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.)
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.)
Please list any allergies:
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Health Questions
Please answer the best you can
Are you unable to sleep in a flat position due to shortness of breath?
Yes
No
Do you have a family history of snoring or other sleep disorders?
Yes
No
Please describe:
Have you ever sustained a brain concussion, head injury or serious blow to the head?
Yes
No
Do you have spells or seizures?
Yes
No
Do you have high blood pressure?
Yes
No
Have you experienced a weight gain in the past year?
Yes
No
How much weight?
Has your shirt collar size increased recently?
Yes
No
By how much?
Do you smoke?
Yes
No
How many pack per day?
How long have you smoked?
Have you quit smoking?
Yes
No
How many pack per day prior to quitting?
How long did you smoke?
Year quit?
Do you drink alcohol?
Yes
No
Please estimate the number of drinks per day. (beer, wine, or liquor)
Do you drink caffeinated drinks?
Yes
No
Please estimate the number of drinks per day. (sodas, coffee, or tea)
Have you gone through menopause?
Yes
No
Have you experienced any prostate issues? (i.e. Frequent urination)
Yes
No
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?
Comes and goes
Occasional
Frequent
Constant
How long has your sleep problem bothered you?
Greater than 2 yrs.
1 - 2 yrs.
Several months
Last 3 months
Within the month
What time do you usually go to bed?
Week days
Hours Minutes
AM
PM
AM/PM Option
Weekends
Hours Minutes
AM
PM
AM/PM Option
What time do you usually wake up?
Week days
Hours Minutes
AM
PM
AM/PM Option
Weekends
Hours Minutes
AM
PM
AM/PM Option
How many hours of sleep do you get?
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)
Day
Evening
Night
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Sleep Questions
How often do you rotate shifts?
Please Select
Never
Rarely
Often
Frequent
Always
Does your job require overnight travel?
Please Select
Never
Rarely
Often
Frequent
Always
Do you drink alcohol after 6pm?
Please Select
Never
Rarely
Often
Frequent
Always
Do you drink caffeinated beverages after 6pm?
Please Select
Never
Rarely
Often
Frequent
Always
Do you suffer from a loss of libido?
Please Select
Never
Rarely
Often
Frequent
Always
Have you experienced difficulties with sexual functions?
Please Select
Never
Rarely
Often
Frequent
Always
Does you sleep problem vary according to the stage of your menstrual cycle?
Please Select
Never
Rarely
Often
Frequent
Always
Have you gone through menopause or had a hysterectomy?
Please Select
Never
Rarely
Often
Frequent
Always
Are you able to fall asleep and awaken on a daily, weekly basis according to your desired schedule?
Please Select
Never
Rarely
Often
Frequent
Always
Do you nap during the day or evening?
Please Select
Never
Rarely
Often
Frequent
Always
Do you feel refreshed after a typical night's sleep?
Please Select
Never
Rarely
Often
Frequent
Always
Do you feel sleepy during the day even when you have slept all night?
Please Select
Never
Rarely
Often
Frequent
Always
Do you feel refreshed after a short nap?
Please Select
Never
Rarely
Often
Frequent
Always
Do you get sleepy while driving?
Please Select
Never
Rarely
Often
Frequent
Always
Have you had an accident or near-accident when driving, due to excessive sleepiness?
Please Select
Never
Rarely
Often
Frequent
Always
Do you fall asleep when you want to stay awake (movies, theater, church, or watching television)?
Please Select
Never
Rarely
Often
Frequent
Always
Are you able fight off the excessive sleepiness?
Please Select
Never
Rarely
Often
Frequent
Always
Do you have memory or concentration problems?
Please Select
Never
Rarely
Often
Frequent
Always
Do you experience vivid dream-like scenes upon awakening or falling asleep?
Please Select
Never
Rarely
Often
Frequent
Always
When you are angry or laugh, do you ever feel weak, as though you might fall?
Please Select
Never
Rarely
Often
Frequent
Always
Are you ever unable to move or speak upon falling asleep or awakening?
Please Select
Never
Rarely
Often
Frequent
Always
Do you have trouble falling asleep when you go to bed?
Please Select
Never
Rarely
Often
Frequent
Always
When you try to fall asleep does your mind race with thoughts?
Please Select
Never
Rarely
Often
Frequent
Always
When you try to fall asleep do you feel pain?
Please Select
Never
Rarely
Often
Frequent
Always
Does pain ever wake you up, disrupt your sleep or keep you from going back to sleep?
Please Select
Never
Rarely
Often
Frequent
Always
Are you a light sleeper, easily awakened?
Please Select
Never
Rarely
Often
Frequent
Always
Is your sleep disrupted because of your bed partner or others in your household?
Please Select
Never
Rarely
Often
Frequent
Always
Do you snore?
Please Select
Never
Rarely
Often
Frequent
Always
Does your snoring stop for brief periods during sleep?
Please Select
Never
Rarely
Often
Frequent
Always
Does your breathing sometimes stop during sleep?
Please Select
Never
Rarely
Often
Frequent
Always
Is your bed partner disturbed by your snoring?
Please Select
Never
Rarely
Often
Frequent
Always
Do you wake up choking or gasping for breath?
Please Select
Never
Rarely
Often
Frequent
Always
Do you have night sweats?
Please Select
Never
Rarely
Often
Frequent
Always
Do you have heartburn at night?
Please Select
Never
Rarely
Often
Frequent
Always
Do you have a bitter bile taste in the back of your throat when you wake up (not "morning breath")?
Please Select
Never
Rarely
Often
Frequent
Always
Do you have nasal / sinus congestion at night?
Please Select
Never
Rarely
Often
Frequent
Always
Do you have morning headaches?
Please Select
Never
Rarely
Often
Frequent
Always
Are you a restless sleeper, tossing and turning at night?
Please Select
Never
Rarely
Often
Frequent
Always
Do you have a creeping crawling sensation in your legs when you lie down to sleep?
Please Select
Never
Rarely
Often
Frequent
Always
Do you experience any type of leg or back pain during the night?
Please Select
Never
Rarely
Often
Frequent
Always
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Rate the following from 1-10 (1 being least and 10 being most painful)
Facial Pain:
Least
1
2
3
4
5
6
7
8
9
Most
10
1 is Least, 10 is Most
Headaches:
Least
1
2
3
4
5
6
7
8
9
Most
10
1 is Least, 10 is Most
Jaw Pain:
Least
1
2
3
4
5
6
7
8
9
Most
10
1 is Least, 10 is Most
Ear Pain:
Least
1
2
3
4
5
6
7
8
9
Most
10
1 is Least, 10 is Most
Neck Pain:
Least
1
2
3
4
5
6
7
8
9
Most
10
1 is Least, 10 is Most
Front/Back Head Pain:
Least
1
2
3
4
5
6
7
8
9
Most
10
1 is Least, 10 is Most
Pain spreads to when having Pain:
Temple
Back of Head
Sensitivity to light
Nausea
Vomiting
Dizziness
(TMJ/TMD) & Pain Concerns
Temporomandibular Joint Disorder (TMJ/TMD) & Pain Concerns
Migraine/Headaches
Right Side
Left Side
Pain in facial area
Right Side
Left Side
Do you have pain around/behind the eyes?
Right Side
Left Side
Grating sound in joint
Right Side
Left Side
Pain in jaw
Right Side
Left Side
Subjective hearing loss
Right Side
Left Side
Pain in neck
Right Side
Left Side
Dizziness (vertigo)
Right Side
Left Side
Pain in shoulder
Right Side
Left Side
Upset stomach/nausea
Yes
No
Ringing sound in ears (tinnitus)
Right Side
Left Side
Fullness/pressure
Yes
No
Do you have pain in the ear?
Right Side
Left Side
Blockage in ear/congestion
Yes
No
Pain in forehead
Right Side
Left Side
Other Pain Questions
Other Pain Questions
What types of pain are you experiencing?
Sharp
Dull
Spreading
Superficial
Aching
Pulsating
Deep
Burning
Is the pain:
Constant
Intermittent
The pain lasts for:
Minutes
Hours
All day
The pain starts:
Suddenly
Gradually
The pain stops:
Suddenly
Gradually
What time of day is the pain most severe?
How often do you have pain?
Monthly
Daily
Weekly
What medication(s), if any, do you take to relieve the pain or have you tried?
Does resting 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?
Yawning
Swallowing
Brushing
Moving shoulders
Chewing
Speaking
Moving head
Moving arms
Singing
Shouting
Moving neck
Moving trunk
Indicate where you feel the pain
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Dysfunction
Can you move your mouth normally?
Completely
Partially
Do you ever open so wide that your mouth locks open?
Yes
No
Do you have any of these sounds in the joint?
Snapping
Grating
If you have any of these problems, is it frequent?
Yes
No
Miscellaneous And Associated Complaints And Questions
Are your jaw muscles ever tired?
Yes
No
Have you had any injury to the jaw or face?
Yes
No
Explain.
Do you attribute the symptoms on anyone incident?
Yes
No
Have you had cortisone injected into a joint?
Yes
No
When?
How many injections?
By whom?
Do you clench your teeth?
Yes
No
Has anyone mentioned that you grind your teeth (brux) at night during sleep?
Yes
No
Have you had any other treatment for this problem?
Yes
No
Explain - medicine, exercise, dental treatment.
Have you had your bite adjusted by your dentist?
Yes
No
When?
How long have you been bothered by this problem?
Is there anyone else in your family with a similar problem?
Yes
No
Explain.
Please describe briefly any changes in location or character of symptoms since this problem began.
Do you chew gum?
Frequently
Moderately
Infrequently
Never
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Submit
Should be Empty: