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Book Now
General Dentistry
Why Choose Us?
Checkups & Cleanings
For Kids
Family Dentistry
Dental Emergencies
Sports Mouthguards
Teeth Grinding
Wisdom Teeth Removal
Cosmetic Dentistry
What’s Right For Me?
Smile Makeover
Tooth Whitening
Invisalign
Veneers
Dental Implants
Botox
Myofunctional Therapy
TMJ
Sleep Apnea
For Patients
Pricing
The Southcentre Experience
What to Expect
Forms
Dentist in SW Calgary
Lake Bonavista Dentist
Willow Park Dentist
Dental Emergencies
About Us
Contact
Blog
Book Now
TMJ Pain Questionnaire
Tell us about your jaw pain or other symptoms.
Step
1
of
2
50%
Name
*
First
Last
Initial
Preferred Name
Gender
*
Gender Pronouns
Address
*
Street Address
Address Line 2
City
Province
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Postal Code
Home Phone Number
Business Phone Number
Your Email
*
Are you a current patient?
*
Yes
No
Preferred Contact Method
*
Email
Phone
Date Of Birth
*
MM slash DD slash YYYY
AHC #
Employer
Occupation
Marital Status
Spouse Employer
PARENTS NAME (IF UNDER AGE 18)
PARENTS BUS
Address
Physician Name
Phone
Address
Dentist Name
Phone
Address
Who referred you to this office ?
INSURANCE INFORMATION (MUST BE COMPLETED BEFORE EXAMINATION DATE)
Dental Insurance
Insured D.O.B.
MM slash DD slash YYYY
Policy #
ID/Certificate #
Insurance Co.
Medical Insurance
Insured Name
Policy #
Insurance Co.
Address
We do not accept workers compensation claims.
Symptoms ( Please Check Any/All Symptoms that you have Experienced)
Headache
Shoulder Pain
Neck Noise
Jaw/Facial Pain with Chewing
Jaw Locking
Facial Numbness
Clenching Teeth
Ear Congestion
Teeth Ache
Back Pain
Difficulty Swallowing
Neck Ache
Facial Pain
Jaw Joint Noise
Jaw/Facial Pain with Yawning
Jaw Fatigue
Facial Swelling
Uncomfortable Bite
Dizziness
Jaw Dislocates
Tingling/Numbness in Hands/Arms
Insomnia/Snoring
Select All
Earache
Eye Pain
Ringing, Buzzing Ears
Limited Jaw Opening
Jaw Stiffness
Limited Movement of Neck
Cheek Biting
Jaw Muscle Tremor
Swelling in Neck
Tinnitus
Please list the 4 most important symptoms you wish to resolve them from the list
Symptom 1
Symptom 2
Symptom 3
Symptom 3
Symptom 4
For each of the pains you have outlined, please indicate the words you feel best describe your pain.
Severity
Headache
*
Mild
Moderate
Severe
Jaw Ache
*
Mild
Moderate
Severe
Neck Pain
*
Mild
Moderate
Severe
Shoulder Pain
*
Mild
Moderate
Severe
Facial Pain
*
Mild
Moderate
Severe
Frequency
Headache
*
Constant
Frequent
Ocassional
Jaw Ache
*
Constant
Frequent
Ocassional
Neck Pain
*
Constant
Frequent
Ocassional
Shoulder Pain
*
Constant
Frequent
Ocassional
Facial Pain
*
Constant
Frequent
Ocassional
Duration
Headache
*
Seconds
Minutes
Hours
All Day
Weeks
Jaw Ache
*
Seconds
Minutes
Hours
All Day
Weeks
Neck Pain
*
Seconds
Minutes
Hours
All Day
Weeks
Shoulder Pain
*
Seconds
Minutes
Hours
All Day
Weeks
CAUSE OF CHIEF CONCERN
The initial cause of my problem was: (Ctrl + click to select multiple choice)
VIRALINFECTION
STRESSFUL PERIOD
DENTAL WORK
OTHER HEAD/NECK PAIN
GRADUAL ONSET
CHEWING INCIDENT
BLOW TO THE HEAD
UPON AWAKENING
PREGNANCY
PHYSICAL FATIGUE
VEHICLE ACCIDENT
GENERAL ANESTHETIC
CERTAIN FOODS
SUDDEN ONSET
TOOTH EXTRACTION
NEW DENTURES
ILLNESS
MENSTRUAL PERIOD
DENTAL ANESTHETIC
BLOW TO THE JAW
My problem is made worse by:
YAWNING
TALKING
FOODS
PREGNANCY
NO REASON
HEAD MOVEMENT
COUGHING
SLEEP
SWALLOWING
STRESS
STRESS
SWALLOWING
SLEEP
PHYSICAL ACTIVITY
FATIGUE
CHEWING
SPECIFIC
SINGING
OPENING WIDE
JAW MOVEMENT
DENTAL VISITS
BENDING OVER
CHEWING
FATIGUE
MENSTRUAL PERIOD
PHYSICAL ACTIVITY
Other
Decreases your pain.
Briefly describe how your problem started and how it reached this state.
SLEEP PATTERN
Do you snore ?
*
Yes
No
Do yo wear a CPAP?
*
Yes
No
Do you gasp for breath during the night?
*
Yes
No
Have you been diagnosed with sleep apnea?
*
Yes
No
Have you had a sleep examination in a sleep centre?
*
Yes
No
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:
Pain on opening
No
Yes
SIDE - Pain on opening
Left
Right
Pain on movement
No
Yes
SIDE - Pain on movement
Left
Right
Pain on close
No
Yes
SIDE - Pain on close
Left
Right
Pain while chewing
No
Yes
SIDE - Pain while chewing
Left
Right
Jaw popping/clicking on opening
No
Yes
SIDE - Jaw popping/clicking on opening
Left
Right
Jaw previously popped/clicked on opening
No
Yes
SIDE - Jaw previously popped/clicked on opening
Left
Right
Jaw Grinding/Granting noise
No
Yes
SIDE - Jaw Grinding/Granting noise
Left
Right
Jaw sometimes locks closed
No
Yes
SIDE - Jaw sometimes locks closed
Left
Right
Can't move jaw
No
Yes
Jaw shifts on opening
No
Yes
DIRECTION - Jaw sometimes locks closed
Left
Right
ZIGZAGZZ
Do neck movements or postural changes increase facial, ear or head pain?
No
Yes
PART - Do neck movements or postural changes increase facial, ear or head pain
Left
Right
Facial
Ear
Head
Do you have difficulty finding a comfortable position at night?
No
Yes
Pain on opening wide (Yawning)
No
Yes
SIDE - Pain on opening wide (Yawning)
Left
Right
Pain at rest
No
Yes
SIDE - Pain at rest
Left
Right
Jaw popping/clicking on closing
No
Yes
SIDE - Jaw popping/clicking on closing
Left
Right
Jaw previously popped/clicked on closing
No
Yes
SIDE - Jaw previously popped/clicked on closing
Left
Right
Limited opening of jaw
No
Yes
Jaw sometimes locks open
No
Yes
Do your job / daily activity involve poor head, neck or back posture?
No
Yes
PART - Do your job / daily activity involve poor head, neck or back posture?
Head
Neck
Back
Any previous examinations / tests for your spine?
No
Yes
PREVIOUS TREATMENT
Please indicate other practitioners i.e.: Physicians, Medical Specialists, Chiropractors, Physical Therapists, etc. that you are seeing or have seen for this problem.
Practitioner Name
Type of Practitioner
Type of Treatment
Result of Treatment
Date of Treatment
MM slash DD slash YYYY
Currently being treated?
Yes
No
Practitioner Name
Type of Practitioner
Type of Treatment
Result of Treatment
Date of Treatment
MM slash DD slash YYYY
Currently being treated?
Yes
No
Practitioner Name
Type of Practitioner
Type of Treatment
Result of Treatment
Date of Treatment
MM slash DD slash YYYY
Currently being treated?
Yes
No
MEDICAL INFORMATION
Height (ft in)
Weight (lbs)
Name of family Physician
Are you being treated for any medical condition at the present or have you been treated within last year
Yes
No
Explain
Please List the name of any medical specialists you have seen in the last 5 years.
Name
Reason
When was your last medical checkup
MM slash DD slash YYYY
Are you taking any medications, non-prescription drugs, vitamins or herbal supplements?*
Yes
No
If yes Explain
Has there been any change in your general health in the past year?*
Yes
No
If yes Explain
Do you Drink Grapefruit Juice?
Yes
No
Have you ever been adviced by your Doctor to take antibiotics before dental treatment?
*
Yes
No
Do you have a bleeding problem or bleeding disorder?
*
Yes
No
Do you Smoke or chew tobacco products?
*
Yes
No
Do you use any recreational drugs?
*
Yes
No
Are you Brest-Feeding?
*
Yes
No
Are you Pregnant or trying to get Pregnant?
*
Yes
No
If Pregnant what is the delivery date?
MM slash DD slash YYYY
Do you have or have you ever had any of the following? Please check
AIDS/HIV
Artificial Joints
Cancer
Drug / Alcohol Dependency
Stomach Ulcers
Headaches
Kidney Trouble
Mitral valve Prolapse
Psychiatric / Psychological
Shortness of Breath
Steroid therapy
Allergies
Asthma
Congential Heart Disease
Epilepsy / Seizures
Thyroid
Hepatitis
Latex sensitivity
Neurological Disorder
Radiation / Chemotherapy
Sickle cell disease
Stroke
Artificial heart valve
Arthritis/Osteoporosis
Diabetes
Heart Attack
Heart Murmur
High Blood Pressure
Liver Disease / Jaundice
Pacemaker
Reaction to Medication / Injection
Sleep Apnea
Tuberculosis
If You have allergies Please list:
Do you have or have you had any disease, condition or problem not listed?*
Yes
No
If yes, Please describe
DENTAL HISTORY
When was your last dental examination / check-up?
Do you have any missing teeth that need replacement?
*
Yes
No
Have you ever been told that you need braces or jaw surgery?
*
Yes
No
Do you have or have you ever had any of the following:
Bite adjustments
Extensive crown / bridge work
Gum treatment
Splint treatment
Removal of wisdom teeth
Orthodontic treatment
OCCLUSION (HOW YOUR TEETH BITE TOGETHER)
Please check off the problems that apply to you:
My teeth fit together evenly (if not, select from the following)
My teeth touch more on the right side than on the left
My back teeth touch more than my front teeth
I feel that one tooth hits upon closing my mouth sooner than the rest
Please check off the problems that apply to you:
My bite feels off centre
My teeth touch more on the left side than on the right
My front teeth touch more than my back teeth
I feel that my lower jaw has shifted backward
Other
GRINDING / CLENCHING
I am aware of doing the following:
*
Day time grinding of teeth
Night time grinding of teeth
Day time clenching of teeth
Night time clenching of teeth
Day time clenching of jaw muscles
Night time clenching of jaw muscles
OCCUPATIONAL CONCERNS
My normal day includes:
Frequent use of the telephone
*
Yes
No
Cradling the phone between my ear and shoulder
*
Yes
No
Prolonged use of a computer / screen
*
Yes
No
Prolonged use of a computer / screen
*
Yes
No
Prolonged driving
*
Yes
No
Repetitive patterns of movements / activity
*
Yes
No
Carrying a heavy briefcase / back-pack
*
Yes
No
Excessive talking / yelling
*
Yes
No
Lifting of heavy objects
*
Yes
No
Holding or turning my head away from centre for prolonged periods of time
*
Yes
No
HABITS / ACTIVITIES (check what applies)
Fingernail biting
Jutting jaw forward
Clenching teeth
Pencil / pen chewing
chin in palm of hands
Contact sports
Singing
Cheek chewing
Clicking jaw habit
Grinding teeth
Gum chewing Holding
Scuba diving
Biking
Select all that apply
Playing a musical instrument with mouth (specifically)
Sleep Habits
Left side
I use more than one pillow
Back
I wake up my partner
I wake up from sleep by pain
Stomach
I sleep with my mouth open
Right side
I snore
In all positions
I sleep on my Select all that apply
If there is anything about your condition that these questions did not ask, give you an opportunity to write about or you feel may be of help in diagnosing or treatment of your problem please feel free to complete this section provided.
ACCIDENT DETAILS
Date Of Accident
MM slash DD slash YYYY
Time
Type of vehicle you were driving
Other vehicle(s) involved
Location
If you have had a previous accident, please describe (include date of accident)
I was
The driver of the vehicle
A passenger in the vehicle
In the front seat
Left In the back seat
Right In the back seat
Middle In the back seat
I was wearing
Seat belt
No seat belt
At the point of impact, I was facing
Forward
Left
Right
Behind
At the time of the accident, do you remember if you hit your
Body Part
Forehead
Face
Chin
Side of head
Back of head
Top of head
Jaw
Teeth
Other
On The
Steering wheel
Windshield
Passenger side window
Driver side window
Headrest
Dashboard
Seat
Roof
Loose object in car
Other person in car
Did your air bag deploye?
*
Yes
No
Do you remember bracing against the steering wheel?
*
Yes
No
Were you rendered unconscious
*
Yes
No
Were you aware that you were going to be hit
*
Yes
No
Were you clenching your teeth at time of impact
*
Yes
No
Did you fracture your teeth or bite your tongue
*
Yes
No
Do you remember receiving a whiplash type of injury
*
Yes
No
Do you remember receiving a sideways whiplash injury
*
Yes
No
How soon after the accident did you notice the following symptoms?
Headache
*
Minutes
Days
1 Week
1-3 Months
More than 3 Months
Neck ache
*
Minutes
Days
1 Week
1-3 Months
More than 3 Months
Shoulder pain
*
Minutes
Days
1 Week
1-3 Months
More than 3 Months
Facial pain
*
Minutes
Days
1 Week
1-3 Months
More than 3 Months
Ear ache
*
Minutes
Days
1 Week
1-3 Months
More than 3 Months
Teeth ache
*
Minutes
Days
1 Week
1-3 Months
More than 3 Months
Neck noise
*
Minutes
Days
1 Week
1-3 Months
More than 3 Months
Jaw joint noise
*
Minutes
Days
1 Week
1-3 Months
More than 3 Months
Limited jaw opening
*
Minutes
Days
1 Week
1-3 Months
More than 3 Months
Pain with chewing
*
Minutes
Days
1 Week
1-3 Months
More than 3 Months
Yawning etc
*
Minutes
Days
1 Week
1-3 Months
More than 3 Months
Ringing,buzzing ears
*
Minutes
Days
1 Week
1-3 Months
More than 3 Months
Dizziness
*
Minutes
Days
1 Week
1-3 Months
More than 3 Months
Facial numbness
*
Minutes
Days
1 Week
1-3 Months
More than 3 Months
Facial swelling
*
Minutes
Days
1 Week
1-3 Months
More than 3 Months
Back pain
*
Minutes
Days
1 Week
1-3 Months
More than 3 Months
Jaw dislocates
*
Minutes
Days
1 Week
1-3 Months
More than 3 Months
Uncomfortable bite
*
Minutes
Days
1 Week
1-3 Months
More than 3 Months
Limited movement of neck
*
Minutes
Days
1 Week
1-3 Months
More than 3 Months
Tingling / numbness in Hands / Arms
*
Minutes
Days
1 Week
1-3 Months
More than 3 Months
How often did you experience the following symptoms before your accident?
Headache
*
Minutes
Days
1 Week
1-3 Months
More than 3 Months
Neck ache
*
Minutes
Days
1 Week
1-3 Months
More than 3 Months
Shoulder pain
*
Minutes
Days
1 Week
1-3 Months
More than 3 Months
Facial pain
*
Minutes
Days
1 Week
1-3 Months
More than 3 Months
Ear ache
*
Minutes
Days
1 Week
1-3 Months
More than 3 Months
Teeth ache
*
Minutes
Days
1 Week
1-3 Months
More than 3 Months
Neck noise
*
Minutes
Days
1 Week
1-3 Months
More than 3 Months
Jaw joint noise
*
Minutes
Days
1 Week
1-3 Months
More than 3 Months
Limited jaw opening
*
Minutes
Days
1 Week
1-3 Months
More than 3 Months
Pain with chewing
*
Minutes
Days
1 Week
1-3 Months
More than 3 Months
Yawning etc
*
Minutes
Days
1 Week
1-3 Months
More than 3 Months
Ringing,buzzing ears
*
Minutes
Days
1 Week
1-3 Months
More than 3 Months
Dizziness
*
Minutes
Days
1 Week
1-3 Months
More than 3 Months
Facial numbness
*
Minutes
Days
1 Week
1-3 Months
More than 3 Months
Facial swelling
*
Minutes
Days
1 Week
1-3 Months
More than 3 Months
Back pain
*
Minutes
Days
1 Week
1-3 Months
More than 3 Months
Jaw dislocates
*
Minutes
Days
1 Week
1-3 Months
More than 3 Months
Uncomfortable bite
*
Minutes
Days
1 Week
1-3 Months
More than 3 Months
Limited movement of neck
*
Minutes
Days
1 Week
1-3 Months
More than 3 Months
Tingling / numbness in Hands / Arms
*
Minutes
Days
1 Week
1-3 Months
More than 3 Months
Are there any other factors you feel are significant with your accident?
Did you go to the hospital?
*
Yes
No
Were you hospitalized?
*
Yes
No
Date that Jaw / facial problems were reported to doctor
MM slash DD slash YYYY
Please describe any previous traumas, to the head, neck or jaw. (sports injury, assault accident etc.)
DEGREE OF IMPROVEMENT
Please grade your degree of pain since your motor vehicle accident on a scale of 1 – 100.
Neck pain
in %
Worse
Improve
Headache
in %
Worse
Improve
Jaw pain
in %
Worse
Improve
Back pain
in %
Worse
Improve
Other
in %
Worse
Improve
If you have had a previous accident, Please describe (include date of accident)
Include date of accident
Are you currently working?
*
Yes
No
On disability insurance?
*
Yes
No
If yes, when are you planing on returning to work?
* Please note that an administrative charge will be payable by yourself if any reports, letters, forms etc. are required to be completed by yourself or a third party. We will notify you of any fee associated with any request before the request is fulfilled.
Appointment Policy
We do require 48 hours’ notice to change or cancel an appointment. It is our policy to personally confirm your appointment prior to the appointment date. Should we be unable to reach you directly or leave you a voicemail, please return our call to confirm your appointment, or your appointment will be lost.
Personal Information & Financial Consent Policy
We are committed to protecting the privacy of our patients’ personal information and to utilizing all personal information in a responsible and professional manner. This document summarizes some of the personal information that we collect, use, and disclose. In addition to the circumstances described in this form, we also collect, use, and disclose personal information when permitted or required by law. We collect information from our patients such as names, home addresses, work addresses, home telephone numbers, work telephone numbers, cell telephone numbers, and email addresses. (Collectively referred to as “Contact Information”) Contact Information is collected and used for the follow purposes: To open and update patient files To invoice patients for dental services, to process credit card payments, or to collect unpaid accounts To send reminders to patients concerning the need for further dental examination or treatment To send patients informational material about our dental practice Contact information is disclosed to third party health benefit providers and insurance companies where the patient has submitted a claim for reimbursement or payment of all or part of the cost of dental treatment or has asked us to submit a claim on the patient’s behalf. Financial information may be collected in order to make arrangements for the payment of dental services. We collect information from our patients about their health history, their family health history, physical condition, and dental treatments (collectively referred to as “Medical Information”). Patients’ Medical Information is collected and used for the purpose of diagnosing dental conditions and providing dental treatment. Patients Medical Information is disclosed: -To third party health benefit providers and insurance companies where the patient has submitted a claim for reimbursement or payment or all or part of the cost of dental treatment or has asked us to submit a claim on their behalf -To other dentists and dental specialists, where we are seeking a second opinion and the patient has consented to us obtaining the second opinion -To other dentists and dental specialists if the patient, with their consent, has been referred by us to the other dentist or dental specialist for treatment -To other dentists and dental specialists where those dentists have asked us, with the consent of the patient, to provide a second opinion -To other health care professionals such as physicians if the patient, with their consent, has been referred by us to the other health care professional for either a second opinion or a treatment If we are ever considering selling all or part of our dental practice, qualified potential purchasers may be granted access as part of the due diligence process to patient information in order to verify information important to the potential sale. If this occurs, we will take steps to ensure that the prospective purchaser safeguards all personal information. Dentists are regulated by the Alberta Dental Association and College which may inspect our records and interview our staff as part of its regulatory activities in the public interest. I authorize Ewart Dental/South Centre Dental to communicate on behalf of myself and all dependents named on my insurance plan, with my insurance company and/or plan administrator with which I may at any time have coverage. I authorize release of personal/financial/dental/medical Information to the same.
Consent
I hereby certify that the medical and dental history is accurate and complete, to the best of my knowledge. I consent to the performing of the dental and oral surgery procedures agreed to be necessary or advisable, including the use of local anaesthetics or any drugs as indicated and I will assume responsibility for all fees associated with those procedures. My signature on this form authorizes submission, including electronic submission and direct assignment, where allowed, for claims for dental services provided. I consent to the collection, use and disclosure of personal information as described herein. I have read and understood the foregoing and agree to the terms and conditions stated herein.
Email
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