Patient Name

Address city zip telephone

Email:

Family Physician specialty

Address city zip telephone

Family Physician specialty

Address city zip telephone

Height weight , age , date of last complete medical exam .

Please circle yes or no. If yes, please fill in details.

Do you have a current medical problem? yes no
What?

Do you have heart trouble? yes no
What kind?

Have you had rheumatic fever? yes no
When?

Do you have high or low blood pressure? yes no
Is it controlled? yes no
How is it controlled?

Have you had pains in the chest or shortness of breath? yes no

Do your ankles ever swell? yes no

Has your physician ever told you that you are anemic? yes no

Have you ever had a stroke? yes no
When?

Do you have diabetes? yes no
How is it controlled?

Are you subject to fainting or dizziness? yes no
When?

Do you have headaches? yes no
How often?

Do you have problems with insomnia? yes no
How often?

Do you have any nervous disorder? yes no
How is it controlled?

Do you take tranquilizers or sedatives? yes no
How often?

Do you take aspirin? yes no
How often?

Are you allergic to any medication? yes no
What?

Have you been advised not to take any medication? yes no
What?

Do you have asthma or hay fever? yes no
How is it controlled?

Have you ever had tuberculosis? yes no
When?

Have you ever been tested for hepatitis? yes no
When?

Have you ever had infectious hepatitis? yes no
When?

Have you ever been tested for aids? yes no
When?

Do you have acquired immune deficiency syndrome (aids)? yes no

Do you have arthritis? yes no
How is it controlled?

Have you ever had a tumor or cancer? yes no
How was it treated?

Have you had any major operations? yes no
What kind?

Have you ever been involved in a serious accident? yes no

Are you taking any medication? Please list

Have you had a significant weight change within the last year? yes no

Lost lbs. - Gained lbs.

Do you become fatigued easily? yes no
At what time of day?

Do you routinely eat breakfast? yes no
What?

Do you take more than one alcoholic drink per day? yes no
How many?

Do you use tobacco? yes no
How much?

Is your diet medically supervised? yes no
For what purpose?

Have you ever experienced problems of prolonged bleeding, either from a cut or dental procedure such as cleaning? yes no

Is/are the symptom(s) due to an accident, injury or work related illness? yes no

Do you have any medical problems not covered by this questionnaire that we need to be aware of?
yes no

For Women:

Are you pregnant? yes no
Expected delivery date?

Do you have any history of previous miscarriages? yes no

Have you reached menopause? yes no
If so, are you taking supportive medication? yes no
Please list medications:

Have you had a hysterectomy? yes no

What aspect of your condition concerns you most?

Are you presently involved with any litigations? yes no

Sympton Check List:

Please check any of the following symptoms which apply to you. (L=left; R=right)

Headaches: Top of head, Temples, Forehead,
Behind eyes, Back of head (occipital)

Pain in neck: L R

Pain in shoulder: L R

Pain in ear: L R

Ear congestion: L R

Dizziness (vertigo): L R

Tinnitus (ringing sound): L R

Pain in jaw joint: L R

Facial pain (nonspecific): L R

Clicking/popping sound in jaw joint: L R

Grating sound in jaw joint: L R

Partial inability to open mouth: yes no constant sporadic

Face muscle twitch: yes no

Difficulty swallowing: yes no

Difficulty breathing through nose: yes no

Difficulty chewing: yes no

Loose teeth (specify):

Occlusal Habits:

Clenching: am pm

Bruxing: am pm

Teeth hit in front first

Cheek biting

Gum chewing

Pipe smoking

Pencil biting

Nail biting

Other:

Postural habits:

Phone cradling

Leans chin on hand

TV watching

Heavy lifting

Shoulder bag

Other: