Orthopedic and TMJ Physical Therapy Center Confidental Health Questionnaire
Jaw & Face Problems
Jaw Related Questions
General Health Questions
Other
When was your last MEdical exam?
Within Last month Within last 6 months More than 6 months
Have you ever been diagnosed for cancer, a tumor, or noticed any lumps or swelling?
Yes No
Do you smoke?
Yes No
Do you drink alcohol? (if so list # per week)
NoBeer Wine Spirits
Education
High school College Graduate Professional Training
Are you currently under the care of a physician / chiropractor / Therapist / Acupuncturist, counselor, etc.?
Please list all medications you are currently taking (prescription and over the counter)?
Name & Dosage
Reason for taking
Indicate what amount you drink of the following in a typical day.
Water (8oz.) Juice (8oz.) Coffee (cups) Tea (cups) Soda (8oz.)
Please Describe your diet.
Allergies : Medication, food or other
Have you ever been treated for any of the following:
Anxiety Nervous Problems Depression Alcoholism Drug Addiction
Do you experience :
Numbness / tingling / weakness in anywhere in your body Urinary leaking or urge with exercise, laughing, coughing, or on the way to the bathroom Pain with urination or sexual activity
Please list any past injuries, accidents and surgeries (include dates if possible) :
Have you ever seen a physical therapist before?
Yes No
Please list exercise, sports, hobbies or musical instruments
Please describe your sleeping habits (Snoring, # of hours, position, # of pillows)
How did you hear about our clinic?
In your own words please describe your problem :
Life Impairment : What are your feeling about your problem on a scale of 1 to 10?
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