INSURANCE INFORMATION (Must be completed before examination date)
If your condition / pain is due to a motor vehicle accident, please complete this section:
Motor Vehicle Insurance (registered owner of vehicle’s insurance)
We do not accept workers compensation claims.
Please indicate the location of your pain on the following diagrams. If your pain starts in one area but radiates to others, please indicate by writing it below with descriptions.
Please list the 4 most important symptoms you wish to resolve them from the list
For each of the pains you have outlined, please indicate the words you feel best describe your pain.
Cause of Chief Concern
Jaw Pain and Function
Please check off the problems that you experience and the side(s) it relates to. Please select left, right or check both boxes if it applies:
Please indicate other practitioners i.e.: Physicians, Medical Specialists, Chiropractors, Physical Therapists, etc. that you are seeing or have seen for this problem.
OCCLUSION (HOW YOUR TEETH BITE TOGETHER)
GRINDING / CLENCHING
Please check the following conditions which apply to your medical history.
All medication currently being taken: (including prescription, homeopathic, supplements & vitamins)
Medications you have previously taken for this problem:
RECENT LIFE EVENTS
My normal day includes:
Playing musical instrument with mouth (specify)
Please Rate Your Response to The following questions by selecting the appropriate number.
0 - None of the time
1 - A little of the time
2 - A moderate amount of the time
3 - Quite a bit of the time
4 - All the time