M2 · Monitoring Myself
Complete at the start of every visit, before anything is adjusted
Synergy Dental Solutions · Dr. Angie Tenholder, DMD, FAACP, DABCDSM, FAGD · 1000 Eleven South, Suite 3F, Columbia, IL 62236 · Phone (618) 281-9729 · Fax (618) 281-9734 · WeCare@WeAreSynergy.com
For patients of every age · Version 4.2 · Complete at the start of every visit, before anything is adjusted
About this visit
Name
*
First Name
Last Name
Date
*
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Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Date of birth
*
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Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Last visit
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Filled in by
Patient
Parent
Together
Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Case ID
PART 1 · HOW THINGS ARE RIGHT NOW
Answer for how things have been since your last visit. On this page, yes means there is something going on.
SINCE YOUR LAST VISIT
Dental
Do you feel that your bite is uneven or unstable?
*
Yes
No
Do you have any tooth or gum soreness?
*
Yes
No
Are you having problems with your appliance fitting well?
*
Yes
No
Have your gums been bleeding?
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Yes
No
Muscular
Are you sore when you touch under your tongue?
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Yes
No
Do you have sore neck muscles?
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Yes
No
Do you have hip or back pain?
*
Yes
No
Joint
Do you have noise coming from your jaw joint when you open and close your mouth?
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Yes
No
Neurological
Are you experiencing anxiety more than usual?
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Yes
No
Are you having headaches?
*
Yes
No
Airway
Are you grinding your teeth?
*
Yes
No
Are you snoring?
*
Yes
No
Are you unable to breathe through your nose? (mouth breathing)
*
Yes
No
PART 1B · YOUR HOMEWORK — HERE, YES IS THE GOOD ANSWER
These three run the other way around from the questions above, so read them carefully.
Homework
Have you been wearing your appliances as instructed?
*
Yes
No
Are you able to do your starfish exercises correctly?
*
Yes
No
Are you able to do your cluck and suck exercise easily?
*
Yes
No
PART 2 · WHAT HAS CHANGED
Check one box on every line. If something has gotten worse, say so — that is as useful to us as an improvement, and it changes what we do next. Use never an issue for anything that has never applied to you.
Compared with your last visit
*
Rows
Better
No change
Worse
Never an issue
Growth and development
Breathing
Sleep quality
Energy through the day
Ability to stay calm and focused
Speech and clarity of speech sounds
Balance and athletic ability
Posture
Head, face or jaw pain
Neck, shoulder or back pain
Bladder control, including at night
Bowel accidents or constipation
Tooth clenching and other movements you cannot control
Mood, attitude and behavior
Of everything above, what changed first, and about how long after your last visit?
PART 3 · OTHER CARE SINCE YOUR LAST VISIT
Anything else going on alongside our treatment — so we can tell later whether a change came from what we did or from something else.
Other care since your last visit
Physical therapy
Chiropractor
Myofunctional or speech therapy
Dentist
Massage therapy
MD (internist or family practice)
Osteopath
Bodywork or craniosacral
Other
Details
Did it help?
Yes
No
Too early to tell
New medication or dose change
Illness, travel, work, school or life events
Anything else you want us to know today?
Submit
Should be Empty: