• Medical Screening & Assessment

    Answer the questions page by page and provide details when prompted (Staff-only fields are hidden).

  • PAGE 1 · About you and Dental Harmony

  • Date of birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Do you have broken teeth or teeth missing because they were broken?*
  • Do you or have you ever been diagnosed with gum disease (periodontitis)?*
  • Are your teeth wearing down and/or getting shorter?*
  • Does your bite feel uneven?*
  • Have you had a history of or been in need of extensive dental work?*
  • Do you have crooked or crowded teeth?*
  • Do you currently use any form of dental appliance therapy? If so, please describe:*
  • Have you ever had trauma to your teeth or jaws? If so, please describe:*
  • Have you always had problems with getting numb or having to return to the dentist for "high spots" and bite adjustments?*
  • Have you had braces or other orthodontic therapy?*

  • PAGE 2 · Muscular Balance

  • Do you feel like your face and neck muscles are tired and sore most of the time?*
  • Do you feel like you can't open your mouth wide enough to eat certain things?*
  • Do you clench and grind your teeth when you are "stressed out"?*
  • Do you have soreness in your neck?*
  • Do you have persistent lower back tightness or pain?*
  • Do you feel like you have to "fidget" to get comfortable?*
  • Do you have pain or "knots" between your shoulder blades?*
  • Do you feel that your ability to rotate or move your head is restricted by pain or discomfort?*
  • Have you ever had a fall, car accident or whiplash? If so, when?*
  • Do you get tension headaches?*

  • PAGE 3 · Joint Stability

  • Do your jaw joints grind, click or pop loud enough to routinely notice?*
  • Do your jaws get stuck open or closed?*
  • Do your jaw joints feel painful to touch when you open?*
  • Do your jaw joints feel painful to touch when your mouth is closed?*
  • Do you feel or hear the clicking and popping of your jaw joint when you place the pads of your pinky fingers in your ears with the pads facing forward?*
  • Do you have congestion or ringing in your ears? (tinnitus)*
  • Do you often feel like you have a "crick in your neck"?*
  • Do you have numbness or tingling of your hands or fingers?*
  • Do you have one leg that is longer than the other?*
  • Which leg?
  • Do you have a "hunchback" appearance? (prominent T1)*

  • PAGE 4 · Neurologic Integrity

  • If you have headaches, please complete the Headache Assessment.
  • Do you have dizziness or lightheadedness?*
  • Do you have ringing in your ears or a feeling of fullness in your ears?*
  • Do you have pain in or around your ears?*
  • Do your eyes feel tired, uncomfortable, and painful or do you get headaches when reading or doing close work?*
  • Do you get car sick or motion sickness?*
  • Do you feel anxiety on a continual basis?*
  • Are you intolerant to temperature extremes?*
  • Do you have a tendency to faint following stressful events?*
  • Do you have a mitral valve prolapse or cardiac arrhythmia?*
  • Have you ever had a concussion or head trauma? If so, when?*

  • PAGE 5 · Airway Sufficiency

  • Do you snore or have you been told that you do on a consistent basis?*
  • Have you been diagnosed with obstructive sleep apnea (OSA)?*
  • Do you feel excessively tired during the daytime, especially when driving?*
  • Is your lower jaw set further back than your upper by more than 4mm (1/4 in)? (overbite)*
  • When your teeth are closed, do your lower teeth become more than halfway covered by your upper teeth? (deep bite)*
  • Are you aware that you clench or grind your teeth at night time?*
  • Do you have headaches or sore facial muscles in the morning?*
  • When you look at yourself in the mirror with your mouth open, are you unable to see the back of your throat?*
  • Are you unable to breathe through your nose with your mouth closed for three minutes?*
  • Do you have chronic nasal blockage and/or allergies?*

  • PAGE 6 · Cellular Vitality

  • Do you have diabetes?*
  • Do you have high blood pressure or heart disease?*
  • Do you have or have you had cancer?*
  • Do you have an autoimmune condition? (Lupus, Fibromyalgia, Raynaud's, Rheumatoid arthritis, Sjögren's, Psoriasis)*
  • Do you have periodontal disease?*
  • Do you have a respiratory disorder? (asthma, emphysema, COPD)*
  • Do you have any other form of chronic illness? If so, what?*
  • Are you currently being treated for anxiety or depression? If so, are you taking any medications? Please list:*
  • Staff entry
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