www.yourdentistisyourartist.com - TMJ & Sleep New Patient Registration Form

TMJ & Sleep New Patient Registration Form

Please note that it is important to fill in all the fields before submitting. Thank you.
Title *
Patient Name *

First NameMiddle NameLast Name
Date of Birth

MonthDayYear
Patient Address*

Street Address

Street Address Line 2

CityState

Zip Code
Home Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Alt. Contact
Please enter a valid phone number.Format: (000) 000-0000.
Employer
Referred By
DDSMDENTDCOther
Health Care Provider
Location
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Family Dentist
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState

Zip Code
Family Physician
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState

Zip Code
PainSleep/AirwayOrthodonticsUnknown
If different than Patient
Responsible Party
Address

Street Address

Street Address Line 2

CityState

Zip Code
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

Rows	Select the Priority	Recent	Chronic (6 mo.+)
Headache Pain
Ear Pain
Jaw Pain
Pain when chewing
Facial Pain
Eye Pain
Throat Pain
Neck Pain
Shoulder Pain
Back Pain
Limited ability to open mouth
Jaw joint locking
Jaw joint noises
Ear congestion
Sinus congestion
Dizziness
Tinnitus (ringing in the ears)
Muscle twitching
Vision problems
Difficulty falling asleep
Swelling in ankles or feet
Morning Hoarseness
Dry mouth upon waking
Fatigue
Kicking or jerking leg repeatedly
Repeated awakening
Tossing and turning frequently
Tooth grinding
Significant daytime drwosiness
Frequent heavy snoring
Affects sleep of others
Gasping when waking
Teeth crowding
Night-time choking spells
Unable to tolerate C-Pap
Told that "I stop breathing" during sleep
Feeling unrefreshed in the morning

YesNo
If "Other" Please Explain *
General AppearanceOverbiteAbility to FunctionSmile
Other Comments
Do any of the above complaints or concerns affect your daily life?
What are the Results You are Seeking from Treatment?
ALLERGIC REACTIONS
AnestheticsCodeinePenicillinAntibioticsLodinePlasticAspirinLatexSedativesBarbituatesMetalsSulfaOther
CURRENT MEDICATIONS
Click (+ Add Row) to add more fields
PREVIOUS TREATMNET/MEDICATIONS FOR THE CONDITION WE ARE EVALUATING
Click (+ Add Row) to add more fields
I release and give my permission for this office to request information and communicate with the providers listed above.
HEALTH AND MEDICAL HISTORY
YesNo
HeadNeckFaceTeatOther
YesNo
YesNo
YesNo
YesNo
YesNo
HEALTH AND MEDICAL HISTORY

Do you have, or have you experienced any of the following:
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
HighLow
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
ChemoRadiation
YesNo
Number of Times*
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
Additional Information
SURGICAL HISTORY

Have you had any of the following:
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
Removal of third molar(wisdom teeth)Other
Other types of surgery
CURRENT SYMPTOMS
Head Pain
LeftRightBilateral
Recent
Chronic (Over 6 mo.)
MidModSevere
Min.Hrs.Days
OccasionalFrequentConstant
LeftRightBilateral
Recent
Chronic (Over 6 mo.)
MidModSevere
Min.Hrs.Days
OccasionalFrequentConstant
LeftRightBilateral
Recent
Chronic (Over 6 mo.)
MidModSevere
Min.Hrs.Days
OccasionalFrequentConstant
LeftRightBilateral
Recent
Chronic (Over 6 mo.)
MidModSevere
Min.Hrs.Days
OccasionalFrequentConstant
LeftRightBilateral
Recent
Chronic (Over 6 mo.)
MidModSevere
Min.Hrs.Days
OccasionalFrequentConstant
Jaw Pain
LeftRight
LeftRight
LeftRight
Jaw Joint Pain
LeftRight
LeftRight
LeftRight
Jaw Locking
YesNo
YesNo
Jaw Joint Symptoms
YesNo
DayNight
YesNo
DayNight
Eye Related Conditions
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
Ear Related Conditions
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
Throat Related Conditions
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
Neck Related Conditions
YesNo
YesNo
YesNo
YesNo
Shoulder Related Conditions
YesNo
YesNo
YesNo
Back Related Conditions
YesNo
YesNo
YesNo
YesNo
YesNo
Mouth and Nose Related Conditions
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
Sleep Conditions

Please select Yes or No answers based on your average sleep experience and/or what a sleep partner has told you.
SideBackStomachVaries
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
Result was
HISTORY OF SYMPTOMS
On what date, or approximate date, did this condition or symptoms first occur?
YesNo
If yes, Please Explain*
YesNo
If yes, please complete Trauma History Section, enclosed as a separate form*
I authorize the release of all examination findings and diagnosis, report and treatment plans, etc., to any referring or treating health care provider. I additionally authorize the release of any medical information to insurance companies, or for legal documentation to process claims. I understand that I am responsible for all charges incurred for my treatment, regardless of insurance coverage.
INDICATE AREAS OF PAIN
Front

Please select the pain aria
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
Back

Please select the pain aria
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
Right Side

Please select the pain aria
1
2
3
4
5
6
Left Side

Please select the pain aria
1
2
3
4
5
6
Authorization to Release Information To the below listed referring and Treating Health Care Professionals
Click (Add Row) for add more fields*
I authorize the release of communications regarding my treatment witht 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.

Rows	Would never doze	Sight chance of dozing	Moderate chance of dozing	High chance of dozing
Sitting and Reading
Watching Television
Sitting, inactive in a public place
As a passenger in a car for an hour without a break
Lying down to rest in the afternoon when circumstances permit
Sitting and talking to someone
Sitting quietly after a lunch without alcohol
In a car, while stopped for a few minutes in traffic

Total Score
Night Time Sleepiness Evaluation - Screening Tool for Sleep Apnea

Rows	Yes	No
1. Snoring - a. Do you snore on most night (>3 nights per week)?
1. Snoring - b. Is your snoring loud? Can it be heard through a door or wall?

Rows	Never	Occasionally	Frequently
2.Has it ever been reported to you that you stop breathing or gasp during sleep?

Rows	Less than 17 inches	More than 16 inches
3. What is your collar size? - Male

Rows	Less than 16 inches	More than 16 inches
3. What is your collar size? - Female

Rows	Yes	No
4. Do you occasionally fall asleep during the day when - a. You are busy or active?
4. Do you occasionally fall asleep during the day when - b. You are diving or stopped at a light
5.Have you had or are you being treated for high blood pressure?

Total Score
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.
Signature*

Clear
Name*

First NameLast Name
Date*

MonthDayYear
Date
Should be Empty:

TMJ & Sleep New Patient Registration Form

Health Care Provider

If different than Patient

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

ALLERGIC REACTIONS

CURRENT MEDICATIONS

PREVIOUS TREATMNET/MEDICATIONS FOR THE CONDITION WE ARE EVALUATING

HEALTH AND MEDICAL HISTORY

HEALTH AND MEDICAL HISTORY

SURGICAL HISTORY

CURRENT SYMPTOMS

Head Pain

Jaw Pain

Jaw Joint Pain

Jaw Locking

Jaw Joint Symptoms

Eye Related Conditions

Ear Related Conditions

Throat Related Conditions

Neck Related Conditions

Shoulder Related Conditions

Back Related Conditions

Mouth and Nose Related Conditions

Sleep Conditions

HISTORY OF SYMPTOMS

INDICATE AREAS OF PAIN

Front

Back

Right Side

Left Side

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

Daytime Sleepiness Evaluation - Epworth Sleepiness Scale

Night Time Sleepiness Evaluation - Screening Tool for Sleep Apnea