CONFIDENTIAL HEALTH QUESTIONAIRE

PATIENT: ……………………………………………......................................  DATE :  .......................................         

WHAT IS THE PATIENT’S CHIEF CONCERN?...................................................................................................

MEDICAL  CONDITIONS

Has the patient ever had any of the following medical conditions? Please circle Yes or No

Arthritis                         Yes   No        Intestinal Disorders                         Yes    No

Allergies                        Yes   No       Hearing Disorders                           Yes    No

Anemia                          Yes   No       Heart Murmur                                 Yes    No

Arteriosclerosis               Yes   No      Hepatitis                                          Yes    No

Asthma                          Yes   No       Heart Problems                                Yes   No

Auto-Immune Disorders              Yes    No           History of Substance Abuse            Yes   No

Birth Defects                 Yes   No        Hypertension (High Blood Pressure)                 Yes    No

Blood Disorders            Yes   No        Hypotension (Low Blood Pressure)                   Yes   No

Bruise easily                  Yes   No        Kidney Disorders                                     Yes    No

Cancer                           Yes   No        Liver Disorders                                        Yes   No

Diabetes                         Yes   No       Nervous Disorders                                    Yes    No

Dizziness                        Yes   No      Numbness of Hands/Arms                        Yes    No

Emotional Problems              Yes    No           Pneumonia                                    Yes    No

Endocrine Disorders              Yes    No           Rheumatic Fever                          Yes    No

Epilepsy                        Yes   No        Swollen, Stiff, Painful Joints        Yes   No

Head or Face Injuries    Yes    No           Shortness of Breath                  Yes   No

Fainting episodes           Yes   No        Any other condition?                   Yes    No

Details/comments regarding relevant medical condition………………………………………………………………………………………….

……………………………………………………………………………………………………………………………………………………..

……………………………………………………………………………………………………………………………………………………..

Please list any medications the patient is/has taken for their medical condition………………………………………..........................................

………………………………………………………………………………………………………………………………………………..

OPERATIONS, ACCIDENTS OR TRAUMA

Has the patient ever had any of the following?

Any serious accidents such as a motor vehicle accident?            Yes   No      

Any whiplash injuries?                                               Yes   No   

Any broken bones?                                                     Yes   No   

Any severe blow to the head or jaw?                          Yes   No      

Concussion or sudden loss of consciousness?             Yes   No

Removal of tonsils, adenoids or appendix                   Yes   No      

Details…………………………………………………………………………………………………………………………………………

PAIN SYMPTOMS

Does the patient have any of the following?

Headaches                                                                     Yes       No

Neck aches or stiff neck muscles                                   Yes       No

Shoulder or back pain                                                    Yes       No       

Earaches                                                                         Yes       No

Jaw aches when chewing or opening wide                     Yes       No

How often are these pains felt and how long do they last?

Details……………………………………………………………………………………………...………………………………………………

What can make the pain worse or when is the pain worse?

Details………………………………………………………………………………………………………………………...……………………

What can make the pain better or when is the pain better?

Details……………………………………………………………………………………………………………………………………………...

What medication is taken for the pain and how often is it taken?

Details………………...……………………………………………………………………………………………………………………………

JAW JOINT SYMPTOMS

Does the patient have any of the following?

“Clicking”, “popping” or “cracking” noise from a jaw joint            Yes       No

A locked jaw so it could not open or close                                       Yes       No

A tired jaw after eating a big meal                                                    Yes       No

Difficulty opening the mouth wide or yawning                                Yes       No

Pain in either jaw                                                                              Yes       No

Details…………………………………………...……………………………………………………………………………………………………

EAR AND EYE SYMPTOMS

Does the patient have any of the following?

Itchiness or stuffiness in either ear                                               Yes       No

Any loss of hearing                                                                      Yes       No

Any pain in, around or behind either ear                                      Yes       No

“Ringing”, “buzzing” or “hissing” sounds in either ear                Yes       No

Grating noises (like sand particles rubbing) in either ear               Yes       No

Details……………………………………………………………………………………………………………………………………………...….

BREATHING SYMPTOMS

Does the patient have any of the following?

Allergies                                                                                    Yes       No

Sinus problems                                                                          Yes       No

Persistent blocked nose                                                             Yes       No

Frequent colds, sore throats and tonsillitis                                 Yes       No

Mouth breathing habit                                                               Yes       No

Snoring during sleep                                                                 Yes       No

Obstructive sleep apnea (OSA)                                                 Yes       No

Details……………………………………………………………………………………………………………………………………………....…

Does the patient have any of the following?

Thumb or finger sucking habit                                                   Yes       No

Speech problems or a lisp                                                           Yes       No

Previous orthodontic treatment                                                    Yes       No

Decayed, missing or filled teeth                                                  Yes       No

Bad breath (halitosis)                                                                   Yes       No

Gum problems (bleeding or puffiness)                                         Yes       No

Details……………………………………………………………………………………………………………………………………………...