• TMJ & Sleep New Patient Registration Form

    Please note that it is important to fill in all the fields before submitting. Thank you.
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  • Health Care Provider

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  • Reason(s) for this appointment

  • If different than Patient

  • What is the Chief Complaint for Which You are Seeking Treatment in Our Office?

    Note- Please Identify Your Chief Complaint as #1, List All Other Symptoms in Priority #2-9
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  • Are there any other things besides the above?*
  • Do you have concerns in any of these areas

  • ALLERGIC REACTIONS

  • Please check any and all medications or substances that have caused an allergic reaction

  • CURRENT MEDICATIONS

  • PREVIOUS TREATMNET/MEDICATIONS FOR THE CONDITION WE ARE EVALUATING

  • HEALTH AND MEDICAL HISTORY

  • Are you currently pregnant?*
  • Have you sustained injury to*
  • Do you drink 4 or more cups of coffee per day?*
  • Do you smoke tobacco?*
  • Have you had prior orthodontic treatments?*
  • Consume alcohol or take sedatives?*
  • Trouble breathing through noe?*

  • HEALTH AND MEDICAL HISTORY

    Do you have, or have you experienced any of the following:
  • Heart Disorder/ Heart Attack*
  • Heart Murmur*
  • Mitral Valve prolaps*
  • Heart Pacemaker*
  • Heart Palpitations*
  • Heart Valve Replacement*
  • Irregular Heartbeat*
  • Blood Pressure*
  • *
  • Stroke*
  • Bleeding Easily*
  • Bruising Easily*
  • Difficulty concentrating*
  • Difficulty breathing at night for sleep*
  • Anemia*
  • Asthma*
  • Birth Defects*
  • Diabetes*
  • Epilepsy*
  • Emphysema*
  • Glaucoma*
  • Gastroesophpgeal Reflex(Gerd)*
  • Hepatitis*
  • History of Substance Abuse*
  • Hypoglyeemia*
  • Huntington's Disease*
  • Kidney Disease*
  • Liver Disease*
  • Leukemia*
  • Migraines*
  • Meniere's Disease*
  • Multiple Sclerosis*
  • Muscular Dystrophy*
  • Neuralgia*
  • Osteoarthritis*
  • Osteoporosis*
  • Ovarian Cyst*
  • Parkinson's Disease*
  • Rheumatic Fever*
  • Rheumatoid Arthritis*
  • Cancer*
  • *
  • Frequent awaking at night*
  • Thyroid Problem*
  • Tuberculosis*
  • Intestinal Disorder*
  • Nervous System Disorder*
  • Anxiety*
  • Skin Disorder*
  • Urinary Tract Disorder*
  • Chronic Fatigue*
  • Fibromyalgia*
  • Cold hands and feet*
  • Depression*
  • Scarlet Fever*
  • Hemophilia*
  • Dizziness*
  • Excessive Thirst*
  • Fainting*
  • Fluid Retention*
  • Frequent colds/flu*
  • Frequent cough*
  • Frequent ear infections*
  • Frequent sore throat*
  • Hearing impairment*
  • Memory Loss*
  • Hay Fever*
  • Insomnia*
  • Muscle aches*
  • Muscle fatigue*
  • Muscle spansms*
  • Muscle tremors*
  • Poor circulation*
  • Psychiatric Care*
  • Recent weight gain*
  • Recent weight loss*
  • Sinus problems*
  • Slow healing sores*
  • Speech difficulties*
  • Swollen, shiff or painful joints*
  • Tired muscles*

  • SURGICAL HISTORY

    Have you had any of the following:
  • General Anesthesia*
  • Tonsils removed*
  • Orthognathic Surgery*
  • Adenoids removed*
  • Jaw Joint Surgery*
  • Other Surgery*
  • Oral Surgery*

  • CURRENT SYMPTOMS

  • Head Pain

  • Location = Frontal (Forehead)
  • Severity
  • Duration
  • Frequency

  • Location = Generalized
  • Severity
  • Duration
  • Frequency

  • Location = Parietal (Top of head)
  • Severity
  • Duration
  • Frequency

  • Location = Occipital (Back of head)
  • Severity
  • Duration
  • Frequency

  • Location = Temporal (Temple area)
  • Severity
  • Duration
  • Frequency

  • Jaw Pain 

  • Jaw pain with opening
  • Jaw pain at rest
  • Jaw pain when chewing

  • Jaw Joint Pain 

  • Jaw sounds with opening
  • Jaw sounds when chewing
  • Jaw sounds at rest

  • Jaw Locking

  • Jaw locks closed*
  • Jaw locks open*

  • Jaw Joint Symptoms

  • Teeth clenching*
  • *
  • Teeth grinding*
  • *

  • Eye Related Conditions

  • Blurred vision*
  • Double vision*
  • Wear of glasses or contact lenses*
  • Extreme sensitivity to light (photophobia)*
  • Eye pain*
  • Pain or pressure behind the eyes*

  • Ear Related Conditions

  • Buzzing in the ears*
  • Ear congestion*
  • Ear pain*
  • Hearing loss*
  • Itchiness or Stuffiness in ears*
  • Pain behind the ear*
  • Pain in front of the ear*
  • Recurrent ear infections*
  • Ringing in the ear(Tinnitus)*

  • Throat Related Conditions

  • Chronic sore throat*
  • Difficulty swallowing*
  • Swollen glands*
  • Constant feeling of a foreign object in throat*
  • Thyroid enlargement*
  • Tightness in throat*

  • Neck Related Conditions

  • Neck pain*
  • Swelling in the neck*
  • Limited movement of neck*
  • Numbness in hands or fingers*

  • Shoulder Related Conditions

  • Shoulder pain*
  • Tingling in hands or fingers*
  • Shoulder stiffness*

  • Back Related Conditions

  • Back pain - lower*
  • Back pain - middle*
  • Back pain - upper*
  • Sciatica*
  • Scoliosis*

  • Mouth and Nose Related Conditions

  • Dry mouth*
  • Chronic sinusitis*
  • Frequent snoring*
  • Burning tongue*
  • Broken teeth*
  • Frequent biting of the check*

  • Sleep Conditions

    Please select Yes or No answers based on your average sleep experience and/or what a sleep partner has told you.
  • Sleep Positions*
  • Is it easy to fall asleep?*
  • Do you wake often during the night?*
  • Do you feel rested upon AM waking?*
  • Gasping or Choking during sleep?*
  • Stopped breathing during sleep?*
  • Have you ever had a Sleep Study (PSG)?*

  • HISTORY OF SYMPTOMS

  • Does any family member have the same or similar problem?*
  • Can you relate your pain or condition to a motor vehicle accident or traumatic injury?*

  • INDICATE AREAS OF PAIN

  • Image field 441

  • Front

    Please select the pain aria

  • Back

    Please select the pain aria

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  • Right Side

    Please select the pain aria

  • Left Side

    Please select the pain aria

  • Authorization to Release Information To the below listed referring and Treating Health Care Professionals

  • t with      including a full report of examination findings, diagnosis, treatment plan, and progress reports to the providers listed above.

  • Daytime Sleepiness Evaluation - Epworth Sleepiness Scale

    The Epworth Sleepiness Scale was developed. and validated by Dr. Murray Johns of Melbourne Australia. It is a simple, self-administered questionnaire - widely used by sleep professionals in quantifying the level of daytime sleepiness.
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  • Night Time Sleepiness Evaluation - Screening Tool for Sleep Apnea

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  • Refer to sleep specialist or order sleep study.


    * 9 poits or more :     Refer to sleep specialist or order sleep study.
    * 6-8 points :              Gray area, use clinical judgment.
    * 5 point or less :       Low probability or sleep apnea.

  • Date*
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