New Patient Questionnaire (Online)

Complete your Occlusal Rehabilitation Centre patient questionnaire before your appointment. This comprehensive form helps Dr. Tejani understand your jaw, bite, TMJ, and overall health history.

OCCLUSAL/TM JOINT AND ORO-FACIAL PATIENT INFORMATION:

Welcome! Jaw and bite problems, and related mouth and facial symptoms, are very difficult to diagnose. They frequently arise from more than one causative factor even though it may appear to have occurred because of a specific incident or injury. For this reason we ask you to complete this questionnaire in full. Many of the questions involve some detail, and may not appear relevant to you, but please answer them. This information will be held confidential and only communicated to those of your choice.

Name(Required)

First Last

Prefer to be called:

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Occupation:

Employer:

Business Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone

Cell Phone(Required)

Fax

Office:

Email(Required)

Preferred Contact Method:

Age:(Required)

Date of Birth:(Required)

Gender(Required)

Marital status:(Required)

Spouse's name:

First Last

Do you have children?(Required)

Boy Ages:

Girl Ages:

Emergency Contact:(Required)

First Last

Emergency Contact Phone Number(Required)

Relationship:(Required)

Are you a member of a dental plan?(Required)

If yes, please bring your plan card or booklet with you.

Referred by:

Reason:

What is your chief complaint?(Required)

Are you in pain at the moment?(Required)

If yes, where is the pain?

When did you first notice the problem?

MEDICAL HISTORY:

Please list the doctors or health practitioners (and indicate their specialty) whom you have consulted for your bite problem.

Physician's name:

First Last

Specialty

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone:

Other physician(s) consulted for your bite problem

Name

Specialty

Phone

Address

Please list all names, if more than one.

Do you have tension headaches?(Required)

Migraine headaches?(Required)

How many migraines or headaches do you have per week?(Required)

Please enter a number greater than or equal to 0.

Describe your general health?(Required)

Do you have low back pain?(Required)

Do you have difficulty sitting for prolonged periods?(Required)

Were you a difficult or forceps delivery at birth?(Required)

Have you recently lost weight unintentionally with good appetite?(Required)

Do injuries or cuts take longer to heal than previously(Required)

Is there a history of diabetes in your family?(Required)

Do injuries or cuts take longer to heal than previously(Required)

Do you suffer from hypoglycemia or low blood sugar?(Required)

Do you urinate 6+ times a day?(Required)

Are you thirsty most of the time?(Required)

Do you wear glasses?(Required)

Do you wear contact lenses?(Required)

Have you had any eye trouble recently?(Required)

Do you have arthritis?(Required)

Do you have ulcers or colitis?(Required)

Do you have psoriasis?(Required)

Do you have acid reflux (heartburn)?(Required)

Do you wear a cardiac pacemaker?(Required)

Are you pregnant/nursing?(Required)

Are you bulimic?(Required)

Are you double jointed?(Required)

Have you had hepatitis/jaundice?(Required)

Do you have gout?(Required)

Do you experience tingling, numbness or pain in your arms, fingers or hands?(Required)

Do you wear arch supports in your shoes?(Required)

Have you ever been told you have one leg shorter than the other?(Required)

If yes, which?

Have you ever had any of the following?(Required)

Select all that apply

Stress and Tension:

Are you on a regular exercise program?(Required)

Describe the activity:

When was your last vacation?

Do you drive a lot?(Required)

Has there been a recent change in your lifestyle such as a change in marital status, childbirth, change of employment, death in the immediate family or other stressful events?(Required)

If yes, which?

Medications:

Please list the names and doses of all the medications you are taking at present.

Be sure to include even those only occasionally taken and birth control or hormone therapy pills if female.

Medication

Dosage

Have you become sick from, shown an allergy to, or been told NOT to take any drugs or medications?(Required)

If yes, which?

Do you have skin reactions to jewellery or irritation between your fingers or on your wrists or forearms?(Required)

Have you ever been told you require pre-medication prior to an invasive procedure?(Required)

Have you ever had an unusual reaction to dental anaesthesia (gas or injection)?(Required)

Have you had injections of steroids such as cortisone?(Required)

Have you had a recent operation for which a general anaesthetic was required?(Required)

Diet and Nutrition:

What meal did you last eat?(Required)

Consisting of:

Are you on a prescribed diet?(Required)

If yes, describe:

Please list the names and doses of all nutritional supplements you are taking at present.

Include occasional. Liquid Multivitamin and Mineral, Magnesium

Do you smoke?(Required)

If yes, what?

Do you drink coffee?(Required)

If yes, how many cups per day?

Please enter a number greater than or equal to 0.

Do you have more than one alcoholic drink per day?(Required)

Ears, Nose and Throat:

Do you have difficulty breathing through the nose?(Required)

Have difficulties with your sense of smell?(Required)

Do you have difficulty swallowing?(Required)

Do you sleep with your mouth open?(Required)

Have problems with taste perception?(Required)

Are you sleepy during the day?(Required)

Do you snore or stop breathing at night(Required)

What position do you usually sleep in?(Required)

Do you experience earaches?(Required)

If yes, which side?

Do you hear sounds or fullness in your ears?(Required)

Any hearing loss?(Required)

Do you have excessive wax in your ears?(Required)

Suffer from dizziness?(Required)

Do you have sinus infections?(Required)

Have post nasal drip?(Required)

Chewing System:

Have you been hit in or fallen on your jaw?(Required)

If yes, when?

Have you been involved in a car accident?(Required)

If yes, when?

Do you swim vigorously or competitively?(Required)

Do you scuba dive?(Required)

Do you hold the phone on your shoulder?(Required)

If yes, which shoulder?

Do you play a musical instrument?(Required)

If yes, which?

Do you sing?(Required)

Do you eat quickly or slowly?(Required)

Do you play with your lips?(Required)

Do you bite your nails?(Required)

Do you chew gum?(Required)

Are you in the habit of keeping anything between your teeth?(Required)

Do you feel that your bite is over-closed?(Required)

Do your jaw muscles tire frequently?(Required)

Do you hear clicking or popping sounds in your jaw joint?(Required)

Do you hear gravel like or grating sounds in your jaw joint?(Required)

Do you have problems in opening your mouth widely?(Required)

Are you aware of clenching or clamping your teeth?(Required)

Have you ever been told that you grind your teeth at night?(Required)

Do you awaken with awareness of your teeth or jaws?(Required)

Do you have sore or sensitive teeth?(Required)

Which side do you chew on?(Required)

Does the jaw problem interfere with your work or activities?(Required)

Dental History

Dentist’s Name:

First Last

Practice Name:

Practice Address:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Practice Phone Number:

Last visit to Dentist:

Reason:

Have you had x-rays or a CT scan of your jaw joints?(Required)

If yes, where/when?(Required)

Have you had orthodontic treatment?(Required)

Have you had your wisdom teeth removed?(Required)

Have you had periodontal (gum) treatment?(Required)

Do you have root canals?(Required)

If yes, How many ?

Do you have extensive crowns and bridges?(Required)

Have you had your bite adjusted?(Required)

If yes, where and when?

Do you wear a removable denture, night guard or bite splint?(Required)

Do you have any missing back teeth which have not been replaced?(Required)

When your lips are at rest, do your teeth touch?(Required)

Have you ever had virus ulcers or cold sores on your face or inside of mouth?(Required)

Do you have a dry mouth?(Required)

Do you have a burning tongue?(Required)

Has your saliva changed in amount or taste?(Required)

Have you ever had your teeth whitened?(Required)

If yes, where?

If yes, how often do you whiten?

When was the last time?

General:

Please describe any other specific or general information which may not have been asked but which your dentists should know.

Have you prepared a narrative report of your symptoms, consultations, treatment and similarly related history as per the letter provided to you upon booking your appointment?(Required)

Any comments or questions you might have?

You will receive an informative pamphlet about jaw joint disorders and any hand-outs which we feel are appropriate for your understanding.

CONSENT:

I would like a copy of my report sent to the following:

Email addresses and postal codes are essential.

Postal Code

New Patient Questionnaire (Online)

OCCLUSAL/TM JOINT AND ORO-FACIAL PATIENT INFORMATION:

MEDICAL HISTORY:

CONSENT:

Contact us today to start living a better life.

(604) 687-3740

1010 Mainland St, Vancouver, BC V6B 2T4

Office Hours