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CDCP
Offering Laughing Gas
Invisalign
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TMJ Care
Laughing Gas (Nitrous Oxide)
Sleep Apnea & Snoring
WHAT WE DO
Check-up and Oral Hygiene
Fillings
Kids Dentistry
Dental Veneers
Dental Implants
Sleep Apnea & Snoring
Crown & Bridge
Root Canal
Extractions
Teeth Whitening
TMJ Care
Dentures
Invisalign
Night & Sports Guard
Oral Cancer Screening
Laughing Gas (Nitrous Oxide)
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TMJ Health Questionnaire
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CDCP
Offering Laughing Gas
Invisalign
TMJ Health Questionnaire
Name:
Date:
Date Of Onset:
Chief Complaint:
PAIN SYMPTOMS
Do you get regular headaches?
Yes
No
Do you get migraine headaches?
Yes
No
Do you get headaches in right or left temple areas?
Yes
No
Do you get headaches in the front or back of your head?
Yes
No
Do you frequently have neck aches or stiff neck muscles?
Yes
No
Have you ever had chronic shoulder or back pain?
Yes
No
Do you clench your teeth during the day?
Yes
No
Do you clench at night?
Yes
No
Do you have trouble sleeping soundly?
Yes
No
Are your jaws tired when you awake?
Yes
No
Do you know if you grind your teeth when asleep?
Yes
No
Are your teeth sore when you awaken?
Yes
No
Are your wisdom teeth extracted?
Yes
No
When are your symptoms worse?
What medication(s), if any, are you taking?
Does anything make you feel better?
How often do you take medication for relief of pain?
TRAUMA OR ACCIDENTS
Have you ever had a severe blow to the head or jaw?
Yes
No
Have you ever been involved in any serious accidents, such as a car accident?
Yes
No
Any whiplash neck injuries?
JAW JOINT SYMPTOMS
Does your jaw feel tired after a big meal?
Yes
No
Do you feel or hear a clicking, popping or cracking noise from either jaw joint?
Yes
No
Are there any foods you avoid eating?
Yes
No
Do you ever get dizzy?
Yes
No
Has your jaw ever locked when you were unable to open or close?
Yes
No
Do you ever feel faint?
Yes
No
Do you ever feel sick?
Yes
No
Do you have difficulty opening wide or yawning?
Is there a family history of jaw joint (TMJ) problems or headaches?
Have you ever had pain in either jaw joint?
Yes
No
Does your jaw ache when you open wide?
Yes
No
EAR AND EYE SYMPTOMS
Do you have any pain in your ears?
Yes
No
Do you wear glasses or contacts?
Yes
No
Do you suffer from loss of hearing?
Yes
No
Does your eyesight blur sometimes?
Yes
No
Do you have itchy/stuffiness in an ear or pain in, around/behind either eye?
Yes
No
Do you hear ringing, buzzing or hissing sounds in either ear?
Yes
No
BREATHING
Do you have allergies?
Yes
No
Is your nose stuffed when you don’t have a cold?
Yes
No
Do you have sinus problems?
Yes
No
Have you been diagnosed with Sleep Apnea?
Yes
No
Do you snore at night?
Yes
No
Have you had a sleep study done at a Sleep Clinic?
Yes
No
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