Sleep-TMJ.com - Registration and Health History

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PLEASE COMPLETE THE FOLLOWING AND WHEN APPROPRIATE PLEASE DESIGNATE HOW LONG SYMPTOMS HAVE BEEN OCCURRING:

NoClicking/poppingGrinding/grating

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chewingears (pain, ringing, dizziness)vision (light sensitivity or blurred vision)

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Authorization must be signed by the patient, or by the nearest relative in the case of a minor or when the patient is physically or mentally incompetent.

REGISTRATION AND HEALTH HISTORY