Medical History
Full Name
*
First Name
Last Name
Phone Number
*
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What is your occupation?
Check the conditions that apply to you or to any members of your immediate relatives:
*
Asthma
Cancer
Cardiac disease
Diabetes
Hypertension
TMJD
Migraine/Chronic headaches
Auto-immune disorder
Mental Health disorder
Check the symptoms and conditions that you're currently experiencing:
*
Respiratory
Cardiac disease
Cardiovascular
Neurological
Mental health disorder
Weight gain
Weight loss
Musculoskeletal
Headaches/Migraines
Cancer
High Blood Pressure
Dental Conditions
Pregnancy
Diabetes
Sleep disorder
Other
If answered "Other", please describe the conditions/symptoms you are currently experiencing.
What is your sleep routine, quality like? (# of hours, quality, the time you go to bed, etc)
Are you currently taking any medication or supplements?
*
Yes
No
If yes, please list the medications/supplements you are taking
What is your weekly exercise routine like?
What is your Gender?
*
Male
Female
Do you use or have history of using mouth guard?
*
Please Select
Yes
No
Are you currently on or have been on orthodontist treatment in the past?
*
Please Select
Yes
No
If yes, please give me the details of your treatment history (dates, treatment progress, any issues during and after the treatment, etc.
Have you had any Botox injection for your TMJD?
Please Select
Yes
No
If yes, please give the details of how the procedure went. (how many times, how long ago, how it helped/didn't help, etc).
Please tell me details of your TMJD history and other symptoms related to it (, headaches, neck and shoulder issues, tongue/lip-tie, etc)
Have you ever had any Manual Therapy (Chiro, Physio, Manual Osteopath, RMT) for your TMJD? If yes, please give details of your treatment.
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