New Patient Form






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AnemiaDiabetes Type 1 or 2HIV/AIDSRheumatic FeverArthritisDrug UseHigh Blood PressureSinus ProblemsArtificial JointsEpilepsyJaundiceSleep ApneaAsthmaFaintingKidney DiseaseSnoringBlood DisordersGastrointestinalLiver ProblemsStrokeBreathing ProblemsGrowth or TumorLow Blood PressureSurgeryCancerHeart AttackMental/Nervous disorderThyroid problemsClotting/BleedingHeart diseaseMigraines/headachesTuberculosisCold SoresHeart MurmurOsteoporosisUlcersDepressionHep AHep BHep CPacemaker


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Does your jaw click or hurt?Do you smoke?Are your jaw muscle soreDo you smoke marijuanaDo you think you grind your teeth?Do you ever have bad breath?Have you ever had orthodontic treatment?Do your gums bleed?Do you wear a night guard?Do you have hot or cold sensitivity?Have you ever had gum disease?Does floss tear between your teeth?Have you ever had your bite adjusted?Does food get stuck in your teeth?Do you bite your lips or cheek?Do your teeth hurt when you bite?Does your mouth often seem dry?Have you been told you have pockets?

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Back /Neck PainEar congestionInsomniaTender/sensitive teethBell’s PalsyFacial PainJoint popping/clickingTingling in fingertipsClenchingGrindingLimited openingTMJ Joint PainDifficulty chewingHeadachesLoose teethTrigeminal NeuralgiaDifficulty swallowingHot/Cold sensitivityRinging in the ears

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