• REGISTRATION AND HEALTH HISTORY

  • DATE
     - -
  • DATE OF BIRTH:*
     - -
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • SEX:*
  • MARITAL STATUS:*
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

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

  • 1. Are you aware of grinding/clenching your teeth?
  • 2. Does your jaw make noise?
  • 3. Has your jaw ever locked?
  • 4. Do you feel that your teeth fit together properly?
  • 5. Do you or have you had:
  • 6. Describe the character of the pain:
  • 7. What relieves the pain?
  • 8. Have you had a traumatic accident or blow to the head?
  • 9. Do you have difficulty with:
  • 10. Have you ever had:
  • 12. Have you ever had TMJ X-rays?
  • 13. Have you ever undergone any type of TMJ treatment?
  • MEDICAL HISTORY: (check any of the following which you have had or have at the present)
  • ALLERGIES OR BAD REACTIONS TO:
  • INFECTIOUS DISEASE OR EXPOSURE TO SOMEONE WITH:
  • SURGERY
  • Do you have any CURRENT HEALTH PROBLEMS?
  • Are you under a PHYSICIAN'S CARE now?
  • Have you been HOSPITALIZED recently?
  • Are there any PHYSICAL OR MENTAL HANDICAPS?
  • Do people complain you snore?
  • Do you fall asleep easily?
  • Do you fall asleep driving, watching TV or reading?
  • Date of last DENTAL EXAM?
     - -
  • Was dental treatment needed?
  • Is future dental treatment needed?
  • Are your teeth sensitive?
  • Are any of your teeth loose?
  • Do your gums bleed easily?

  • WOMEN ONLY

  • Are you PREGNANT?
  • Have you reached MENOPAUSE?
  • Are you taking ORAL CONTRACEPTIVES?

  • I authorize the release of any medical/dental records to process this claim.

  • 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.

  • Should be Empty: