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TMJ Health History

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 TMJ Health History

  • TMJ Health History

  • MM slash DD slash YYYY
  • 1. Are You Experiencing Any Of The Following?

  • 2. What Are The Chief Complaints For Which You Are Seeking Care? Please Order Complaints By Number (1 = Most Important, 10 = Least)

  • 3. Please List Treatments You Have Received, As Well As Health Care Professionals You Have Seen

  • Include the name of the practitioner, their specialty, the treatment you received, and the approximate date of treatment.
  • 4. The Epworth Sleepiness Scale

  • The Epworth Sleepinedd Scale (ESS) was developed and validated by Dr. Murray Johns of Melbourne, Australia. Is is a simple, self-administered questionnarie that is widely used by sleep professionals in quantifying the level of daytime sleepiness.

    How likely are you to dose off or fall asleep in the following situations, in contrast to feeling "just tired?" This refers yo your usual way of life at present and in the recent past. Even if you have not done some of these things recently, try to work out how they would have affected you.

    Use the following scale to choose the most appropriate number for each situation:

    1 = would never doze

    2 = slight chance of dozing

    3 = moderate chance of dozing

    4 = high chance of dozing

  • 5. Please Indicate any Medications/Substances Which Have Caused an Allergic Reaction

  • 6. Please List All Medications Currently Being Taken

  • 7. Please Complete the Following Medical/Dental History

  • 8. Please Provide Information Regarding Your Current Condition

  • 9. Where is Your Pain?

  • Please Check Pain Location, Severity, Frequency and Duration
  • 10. Please Indicate any Jaw Problems You are Experiencing

  • 11. Please Indicate Any Eye, Ear, Mouth and/or Nose Problems

  • 12. Please Indicate Any Throat, Neck, and/or Back Symptoms

  • 13. Please Indicate Any Accident(s) and/or Traumatic Incidents

  • I Certify That the Above History is True and Correct to the Best of My Knowledge

After submitting, feel free to return to the Patient Forms page. Please note, there are multiple forms for each section.

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