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Health History Form

As required by law, our office adheres to written policies and procedures to protect the privacy of information about you that we create, receive, or maintain. Your answers are for our records only and will be kept confidential subject to applicable laws. Please note that you will be asked some questions about your responses to this questionnaire and there may be additional questions concerning your health. This information is vital to allow us to provide appropriate care for you. This office does not use this information to discriminate.

PERSONAL INFORMATION

Prefered Method of Contact

MEDICAL INFORMATION

Have you had any of the following?

Constitutional

Unexplained appetite changes
Unusual weakness
Recent trauma
Recent infection
Tire easily
Recent marked weight changes
Sensitivity to heat or cold
Night sweats

Head

Chronic facial pain
Chronic headache pain
Day-time
Night-time

Neck

Neck pain
Swelling
Stiffness

Eyes

Double vision
Blurred vision

Ears

Stuffiness in ears
Ringing in ears
Discharge
Ear pain

Nose

Change of smell (not associated with illness)
Nasal obstruction (not associated with illness)
Excessive sneezing
Nasal allergies
Frequent sinus infections

Throat

Chronic soreness
Chronic hoarseness
Difficulty swallowing

Cardiovascular

High Cholesterol
Atrial Fibulation
Stroke
Heart murmur
Rheumatic fever
Palpitations
Chest pain
High blood pressure
Chest tightness
Swelling of ankles
Heart attack

Pulmonary

Persistent cough
Labored breathing
Hard to breath laying down
Yellow or green sputum
Wheezing
Pneumonia
Tuberculosis
COPD
Asthma

Gastrointestinal

Unexplained nausea
Chronic Diarrhea
Chronic constipation
Heartburn
GERD (reflux)
Hepatitis (liver disease)

Genitourinary

Kidney disease
Difficulty urinating
Loss of libido

Musculoskeletal

Pain in joints
Joint injections
Joint or muscle pain that alters sleep position
Restless leg syndrome
Fibromyalgia

Neurological

Loss of memory
Disorientation
Fainting
Dizziness
Vertigo
Clumsiness
Muscle paralysis
Muscle weakness
Depression
ADHD
Anxiety

Endocrine

Thyroid condition
Adrenal condition
Cortisone treatments
Bleeding
Diabetes I
Diabetes II

Women

Pre-menopausal
Peri-menopausal
Post-menopausal
Could you be pregnant?
Hot flashes
Are you nursing?

Have you or any family member have history of the following?

Snoring
Obstructive Sleep Apnea
Heart Disease
Depression
Obesity
Cancer
Are you current with your childhood immunizations?

Emergency Information

Have you been evaluated at a sleep disorders center before?
Have you had any surgeries to treat your sleep symptoms?
Do you work varying shifts or nighttime shifts?
Have you been treated with CPAP?

Social History

Do you smoke tobacco?
If you smoke tobacco, do you smoke when you wake up during the night?
If you smoke, have you noticed that nicotine alters or interferes with your sleep?
Do you usually drink coffee, tea, chocolate, cola or other caffeinated beverages with in 3 hours of your bedtime?
How many of the following caffeinated drinks do you have per day?
Do you drink alcoholic beverages?
Assuming the following drinks are equivalent-12oz. beer/5 oz. Wine/3 oz vodka etc. then:
Do you drink alcohol within two hours of bedtime?
Do alcoholic beverages alter or interfere with you sleep?
Have you ever used alcohol in order to get to sleep?
Have you ever sought treatment/counseling for an alcohol problem?

TMJ History

Have you experienced any of the following?

Night time grinding
Night time clenching
Daytime clenching
Use of occlusal guard to prevent grinding and/or clenching
History of joint locking
Clicking in right joint
Clicking in left joint
Headaches caused by TMD
Facial muscle pain

Drug and Other Allergies

Are you allergic to any drugs?

Epsworth Sleepiness Scale

How likely are you to doze off or fall asleep in the following circumstances, in contrast to feeling just tired? This refers to your usual way of life in recent times. Using the scale below, select the most appropriate number for each situation.

Scale: 0 - Would Never Fall Asleep 1 - Slight Chance of Dozing 2 - Moderate Chance of Dozing 3 - High Chance of Dozing
Overall quality of sleep

Update Form

Have you been ill at all during the last two weeks?
Any respiratory symptoms, viral symptoms or fever or have you travelled to a foreign country during the last two weeks?
Did you travel out of the country in the last two weeks?
Were you exposed to anybody who tested positive for Corona Virus in the last 2 weeks?

Signature

NOTE: Both Doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment.

All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.
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Thank You!

We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.

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