Health History Form

Medical Insurance*
Dental Insurance
Referring Doctors*
Referring Doctor and other Doctors you would like to have reports sent to. Please include their full name and address.
Primary Care Physician’s Name, address and phone number
Pharmacy Name and Phone #:
Allergies (if No Known Allergies type N/A) List all allergies to medications and the reaction you had to any medicine (or any other allergies):

Epworth Sleepiness Scale: How likely are you to doze off or fall asleep in the following situations, in contrast to just feeling tired? This refers to your usual way of life in recent times. Even if you have not done some of these things recently, try to work out how they would have affected you: Use the following scale to choose the most appropriate number for the situation: 0 = would never doze 1 = slight chance of dozing 2 = moderate chance of dozing 3 = high chance of dozing
Sitting and reading
Watching TV
Sitting, inactive, in a public place (theater, meeting, etc.)
As a passenger in a car for an hour without a break
Lying down to rest in the afternoon when circumstances permit
Sitting and talking to someone
Sitting quietly after a lunch without alcohol
In a car, while stopped for a few minutes in traffic

Do you have jaw problems?
Do you have jaw pain?
Do you have clicking or other noises in your jaw joint(s)?
Do you have difficulty opening or closing your mouth?
Please describe any jaw or face problem(s) that you may have:
Is nausea associated with your pain?
Is vomiting associated with your pain?
Does your pain increase with bright lights?
Does your pain increase with bright lights?
Does your pain increase with loud noises?
Does physical activity make your pain:
Do you get an aura (flashing lights, zigzags, blindness, smells)?
If yes, describe:
Does your pain wake you from sleep?
Does your pain keep you from falling asleep?
Do any of your family members have the same or similar pain problem?
Do any of these occur with your pain:
- Eyelid drooping
- Redness of the eye(s)
- Tearing of the eye(s)
- Face sweating
Is your pain:
If your pain is intermittent how often does it occur?
How long does your pain last?
CURRENT MEDICATIONS: List ALL medicines you are CURRENTLY taking for medical and pain problems

Including prescribed, over-the-counter, herbs, and vitamins. Also, be sure to include: Name. Strength, Number of Times Per Day, Prescribing Doctor, and Date Started

Highest Level of Education Completed
- GED
- High school
- Vocational
- College
- Graduate
- Other
If Other Please Describe
List the name of the person or person’s you live with and their relationship to you.
What is your current employment status?
Your current or most recent occupation:
Are you on disability?

Do you have any legal action pending related to this pain or any other health issue?
- Yes
- No
If yes, please list the attorney’s name, address, and phone number:

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