Patient Health Questionnaire

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Do you have concerns in any of these areas:

General Appearance

Ability to Function

Overbite

Smile

Other Comments

Do any of the above complaints or concerns affect your daily life?

What are the results you are seeking from treatment?

Patient Signature

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Date:-------------

CURRENT MEDICATIONS

Please list all medications you are taking and the reason you take them. Include all over-the-counter medications, vitamins, herbs, etc.:

Medication

Dosage

Reason for Taking

See attached list

PREVIOUS TREATMENTS / MEDICATIONS FOR THE CONDITION WE ARE EVALUATING

Treatment and / or Medication

Doctor / Provider Name

Approximate Date of Treatment

I release and give my permission for this office to request information and communicate with the providers listed above:

Patient Signature

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Date:-------------

Parent / Guardian Signature (if patient is minor)

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Date:-------------

Additional Information

Other types of surgery

Current Symptoms : Head Pain

CURRENT SYMPTOMS CONTINUED

History of Symptoms

On what date, or approximate date, did this condition or symptoms first occur?

Does a family member have the same or similar problems?

Yes No

Can you relate your pain or condition to a motor vehicle accident or traumatic injury?

Yes No

I authorize the release of all examination findings and diagnosis, report and treatment plans, etc., to any referring or treating health care provider. I additionally authorize the release of any medical information to insurance companies, or for legal documentation to process claims. I understand that I am responsible for all charges incurred regardless of insurance coverage.

Patient Signature:

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Date:-------------

Parent / Guardian Signature (if patient is minor)

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Date:-------------

DAYTIME SLEEPINESS EVALUATION: EPWORTH SLEEPINESS SCALE

The Epworth Sleepiness Scale was developed and validated by Dr. Murray Johns of Melbourne Australia. It is a simple, self-administered questionnaire - widely used by sleep professionals in quantifying the level of daytime sleepiness.

For the following situations, answer with one of the following numbers:
0 = Would Never Doze 1 = Slight Chance of Dozing 2 = Moderate Chance of Dozing 3 = High Chance of Dozing

SITUATION

SCORE

Sitting and reading

Watching television

Sitting, inactive in a public space

As a passenger in a car for an hour without a break

Lying down to rest in the afternoon when circumstances permit

Sitting and talking to someone

Sitting quietly after a lunch without alcohol

In a car, while stopped for a few minutes in traffic

TOTAL SCORE:

Patient Signature:

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Date:-------------

NIGHTTIME SLEEPINESS EVALUATION: SCREENING TOOL FOR SLEEP APNEA

Developed by David White, M.D., Harvard Medical School, Boston, MA
Please answer the following questions:

SITUATION

SCORE

Do you snore on more than 3 nights per week? Yes = 2 • No = 0

Is your snoring loud? Can it be heard through a door or wall? Yes = 2 • No = 0

Has it ever been reported to you that you stop breathing or gasp during sleep?
Never = 0 • Occasionally = 3 • Frequently = 5

What is your collar size?
Male: Less than 17 inches = 0 • More than 17 inches = 5
Female: Less than 16 inches = 0 • More than 16 inches = 5

Do you occasionally fall asleep during the day when:

You are busy or active: Yes = 2 • No = 0

You are driving or stopped at a light: Yes = 2 • No = 0

Have you had or are you being treated for high blood pressure? Yes = 1 • No = 0

TOTAL SCORE

Patient Signature

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Date:-------------

AUTHORIZATION TO RELEASE INFORMATION TO THE BELOW LISTED REFERRING AND TREATING HEALTH CARE PROFESSIONALS:

DOCTOR'S NAME

LOCATION

PHONE

Date:-------------

Name

Address

City/State/Zip

Phone

I understand and agree to have the indicated professionals I have listed above and initialed be sent information and ongoing updates regarding my diagnoses and treatment.

Yes No

I do not wish to have my records sent at this time.

Yes No

I certify that the above information is correct to the best of my knowledge.

Patient/Guardian Signature

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Date:-------------

Patient Health Questionnaire

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DEMOGRAPHIC INFORMATION

PATIENT INFORMATION

PLEASE CHOOSE YOUR TOP TEN SYMPTOMS BELOW. THEN RATE THEM IN ORDER FROM 1-10 WITH #1 BEING THE MOST IMPORTANT TO YOU, #2 THE NEXT MOST IMPORTANT, AND SO ON.

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Allergies & Medications

Please check any and all medications or substances that have caused an allergic reaction:

CURRENT MEDICATIONS

PREVIOUS TREATMENTS / MEDICATIONS FOR THE CONDITION WE ARE EVALUATING

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Click to Sign

HEALTH AND MEDICAL HISTORY

Do you have, or have you experienced any of the following:

Additional Information

SURGICAL HISTORY

Have you had any of the following:

Other types of surgery

CURRENT SYMPTOMS

Current Symptoms : Head Pain

Frontal (forehead)

Generalized

Parietal (Top of Head)

Occipital (Back of Head)

Temporal (Temple Area)

CURRENT SYMPTOMS CONTINUED

Jaw Pain

Jaw Locking

Jaw Joint Symptoms

Eye Related Conditions

Ear Related Conditions

Throat Related Conditions

Neck Related Conditions

Shoulder Related Conditions

Back Related Conditions

Mouth and Nose Related Conditions

Sleep Conditions:

HISTORY OF SYMPTOMS

History of Symptoms

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SLEEPINESS EVALUATION

DAYTIME SLEEPINESS EVALUATION: EPWORTH SLEEPINESS SCALE

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NIGHTTIME SLEEPINESS EVALUATION: SCREENING TOOL FOR SLEEP APNEA

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AUTHORIZATION TO RELEASE INFORMATION TO THE BELOW LISTED REFERRING AND TREATING HEALTH CARE PROFESSIONALS:

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FAMILY PHYSICIAN

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DENTIST

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CHIROPRACTOR

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PHYSICAL THERAPIST

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ENT

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CARDIOLOGIST

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ALLERGIST

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NEUROLOGIST

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PSYCHIATRIST

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PSYCHOLOGIST

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PULMONOLOGIST

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PHARMACY

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