Patient Health Questionnaire

Demographic InformationToday’s Date:

Last Name: Middle Initial: First Name:

Single Married Widowed Separated Divorced

Age: Date of Birth: SSN: Sex: Male Female

American Indian/Alaska Native Asian Black/African American Hispanic/Latino

Native Hawaiian/Pacific Islander White Other Decline

Occupation:

Ethnicity:

Responsible Party/Legal Guardian (if different than patient): Relationship to Patient:

Contact InformationAddress: Address 2:

City: State: Zip Code:

Email: Employer:

Home Phone:

Provider InformationDental Provider Office: Last Visit:

Dentist Name: Office Phone:

City: State: Zip Code:

Primary Care Physician Office: Last Visit:

Doctor Name: Office Phone:

City: State: Zip Code:

Additional Provider Office (if applicable): Last Visit:

Doctor Name: Office Phone:

City: State: Zip Code:

Last Visit:

Office Phone:

City: State: Zip Code:

Additional Provider Office (if applicable):

Doctor Name:

For Office Use Only - Date of Completion:

Patient Initials: PHQ | Page 1

Referral Information - how did you hear about us?

Referral Name/Source:

DoctorReferral Type: Dentist Specialist Patient Other

Cell Phone: Work Phone:

_____

Pain and Sleep Center of Delaware620 Churchmans Road

Newark DE, 19702

Current Symptoms

TMD / Pain Orthodontics Myofunctional TherapyReason(s) for this appointment:

Please number your chief complaint as 1 and all other complaints starting at 2 and increasing numerically:

___Back Pain___Difficulty Closing Mouth___Dizziness___Dyskinesia___Ear Congestion___Ear Pain___Ear Stuffiness___Eye Pain___Facial Pain___Headache (inside head)___Headache (outside head)___Jaw Joint Locking___Jaw Joint Noises___Jaw Pain___Limited Ability to Open___Muscle Twitching

___Neck Pain___Nerve Pain___Numbness___Pain When Chewing___Shoulder Pain___Sinus Congestion___Throat Pain___Tinnitus (Ringing in Ears)___Vision Problems___Acid Indigestion___Affecting Sleep Partner___Difficulty Falling Asleep___Dry Mouth Upon Waking___Fatigue___Feel Unrefreshed in Morning___Frequent Heavy Snoring

___Frequent Tossing & Turning___Kicking/Jerking Legs Repeatedly___Morning Headaches___Morning Hoarseness in Voice___Night Sweats___Nighttime Choking Spells___Nighttime Urination___Repeated Awakening___Short of Breath___Sore Jaw Upon Waking___Swelling in Ankles/Feet___Teeth Crowding___Teeth Grinding___Told I Stop Breathing During Sleep___Unable to Tolerate CPAP___Vivid Dreams

What is your level of head, neck, and facial pain? 0 = no pain to 10 = worst possible pain:

Currently: At its best: At its worst:

What results are you seeking from treatment?

Please check any dental symptoms that you are currently experiencing:

___Changes in bite___Dental Changes

___Teeth Spacing___None

___Teeth Crowding___Teeth Sensitivity

Any symptoms not listed above?

In which position do you sleep?

Where do you sleep?

Do you have a bed partner?

Is it easy for you to fall asleep?

How many times do you wake during the night?

Do you feel rested upon waking?

Has anyone ever told you that you stop breathing during sleep?

Have you ever had a sleep study?

back side stomach varies

bed chair couch other

yes no

yes no

yes no

yes no

yes no

If yes: Date: ____________ Location: __________________

Patient Initials: PHQ | Page 2

Sleep / Airway

Pain and Sleep Center of Delaware620 Churchmans Road

Newark DE, 19702

Patient Initials: PHQ | Page 3

Medications

Please list all medications you are currently taking and the reason you are taking them. Include prescription, over thecounter, vitamins, herbs, etc. (Please attach additional sheet if necessary)

Previous treatments/medications for the condition we are evaluating:

Medication Dosage Reason for Taking

Treatment/Medication Doctor/Provider Approximate Date of Treatment

Allergies

Medical History

___Anesthetics___Antibiotics___Aspirin___Barbiturates

___Penicillin___Plastic___Sedatives___Sulfa

___Codeine___Iodine___Latex___Metals

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

Other:_________________________________________

Other:_________________________________________

Other Surgeries:_________________________________

If yes, what:

Have you had prior orthodontic treatment?Have you had sustained injury to: head face neck teeth

yes no

Please indicate if you have had any of the following:

___General Anesthesia___Adenoids Removed___Tonsils Removed

___Removal of Wisdom Teeth___Nasal Surgery

___Jaw Joint Surgery___Orthognathic Surgery___Oral Surgery

Do you have trouble breathing through your nose?

Are you currently pregnant?

Do you drink 4 or more cups of coffee per day?

Do you smoke tobacco?

Do you consume alcohol?

Do you take any sedatives/medications/supplements to help yourself fall asleep at night?

yes no

yes no

yes no

yes no

yes no

yes no

if yes: habitually socially

Pain and Sleep Therapy Center has my permission to obtain my complete medication history, including electronic prescription submission

If yes, who:_________________________________

_____

_____

Pain and Sleep Center of Delaware620 Churchmans Road

Newark DE, 19702

Patient Initials: PHQ | Page 4

Medical History, Continued

Do you have or have you experienced any of the following?

___AIDS/HIV___Anemia___Anxiety___Asthma___Birth Defects___Bleeding Easily___Bruising Easily___Cancer___Chronic Fatigue___Cold Hands and Feet___Depression___Diabetes___Difficulty Breathing at Night___Difficulty Concentrating___Dizziness___Eating Disorder___Ehlers-Danlos Syndrome (EDS)___Emphysema___Epilepsy___Excessive Thirst___Fainting___Fibromyalgia___Fluid Retention___Frequent Awakening at Night___Frequent Colds/Flus___Frequent Cough___Frequent Ear Infections___Frequent Sore Throat___Gastroesophageal Reflux (GERD)___Glaucoma

___Hay Fever___Hearing Impairment___Heart Disorder/Heart Attack___Heart Murmur___Heart Pacemaker___Heart Palpitations___Heart Valve Replacement___Hemophilia___Hepatitis___High Blood Pressure___History of Substance Abuse___Huntington’s Disease___Hypoglycemia___Insomnia___Intestinal Disorder___Irregular Heartbeat___Kidney Disease___Leukemia___Liver Disease___Low Blood Pressure___Memory Loss___Meniere’s Disease___Migraines___Mitral Valve Prolapse___Muscle Aches___Muscular Dystrophy___Muscle Fatigue___Muscle Spasms___Muscle Tremors___Multiple Sclerosis

___Nervous System Disorder___Neuralgia___Osteoarthritis___Osteoporosis___Ovarian Cyst___Parkinson’s Disease___Poor Circulation___Postural Orthostatic Tachycardia

Syndrome (POTS)___Psychiatric Care___Recent Weight Gain___Recent Weight Loss___Rheumatoid Arthritis___Rheumatoid Fever___Scarlet Fever___ Seizures___Shortness of Breath___Significant Daytime Drowsiness___Sinus Problems___Skin Disorder___Slow Healing Sores___Sleep Apnea___Speech Difficulties___Stroke___Swollen, Stiff, or Painful Joints___Thyroid Problem___Tired Muscles___Tuberculosis___Urinary Tract Disorder

Does your family have a history of similar conditions, symptoms, or diseases? yes no

Have you been prescribed a CPAP?

Do you use it as prescribed?

Have you had a previous oral appliance, mouthguard, splint, retainer?

Do you use it as prescribed?

How many hours of sleep, on average, do you get per night?

How many hours of sleep, on average, during the day?

Do you ever cough, gasp, or snort upon waking?

yes noyes no

yes no

yes no

If yes, please explain (optional):____________________________________________________

Have you ever experienced: (Optional - check applicable)

___Physical Abuse ___Verbal Abuse ___Emotional Abuse ___Sexual Abuse ___None

yes no

Left Right Bilateral Recent Chronic Mild Moderate Severe Min. Hrs. Days Occasional Frequent Constant(over 6 mo.)

Pain and Sleep Center of Delaware 620 Churchmans Road

Newark DE, 19702

Patient Initials: PHQ | Page 5

Are you currently experiencing head pain?If yes, please indicate all that apply:

yes no

Location Time Frame Severity Duration Frequency

yes no

left rightleft rightleft rightleft rightleft rightleft right

Are you currently experiencing jaw conditions?If yes, please indicate all that apply:

Jaw pain with openingJaw pain when chewingJaw pain at restJaw sounds with openingJaw sounds when chewingJaw sounds at rest

___Jaw Locks Closed___Jaw Locks Open___Daytime Teeth Clenching/Grinding

___Pain/Pressure behind eyes___Extreme Sensitivity to light___Wear Glasses or Contact Lenses

___Nighttime Clenching/Grinding___Blurred Vision___Double Vision

Please indicate if you have had any of the following:

yes noAre you currently experiencing any ear related conditions?If yes, please indicate all that apply:

left rightleft rightleft rightleft rightleft rightleft right

Ear CongestionEar PainHearing LossItchiness or Stuffiness in EarsPain Behind the EarPain in Front of the EarRecurrent Ear InfectionsRinging in the Ear

left rightleft right

Currently Experiencing

Temple Area (Temporal)Back of Head (Occipital)Forehead (Frontal)Top of Head (Parietal)General Head Pain

Please indicate your areas of pain by labeling the body and head diagrams with the appropriate numbers below.

1 - Mild Pain 2 - Moderate Pain 3 - Severe Pain

PHQ | Page 6

If yes, who: ___________________________________

yes no

yes no

yes no

If yes, please explain: ___________________________________

Pain and Sleep Center of Delaware 620 Churchmans Road

Newark DE, 19702

Please indicate if you have had any of the following:

___Chronic Sore Throat___Difficulty Swallowing___Swollen Gland___Thyroid Enlargement___Tightness in Throat___Constant Feeling of Foreign

Object in Throat___Limited Movement of Neck

___Middle Back Pain___Scoliosis___Sciatica___Chronic Sinusitis___Broken Teeth___Dry Mouth___Frequent Biting of the Cheek___Burning Tongue Sensation

___Neck Pain___Numbness in hands/fingers___Swelling in the neck___Shoulder Pain___Shoulder Stiffness___Tingling in hands or fingers___Lower Back Pain___Upper Back Pain

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

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

If yes, please explain:

Does any family member have a sleep breathing disorder or Obstructive Sleep Apnea?

Does any family member have the same or a similar problem?

Symptom History

Additional Information

Is there anything else you would like us to know?

Signature

I agree, the above information is accurate and complete to the best of my knowledge.

Patient Signature: __________________________________________________________________Date: _____________________

Parent/Guardian Signature: __________________________________________________________Date: _____________________