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Comprehensive Health Questionnaire
Vivos > Comprehensive Health Questionnaire

Patient Information:


Do you currently experience any of the following symptoms?

Number your top 5 symptoms 1 through 5

Headache (inside your head)
Dizziness
Headache(outside your head)
Ringing in Ears (Tinnitis)
Jaw Pain
Vision Problems
Chewing Pain
Muscle Spasm
Face Pain
Sinus Congestion
Eye Pain
Kicking or jerking leg repeatedly
Throat Pain
Swelling in ankles or feet
Neck Pain
Numbness (Localized)
Shoulder Pain
Nerve Pain
Back Pain
Dental Changes
Dyskinesia
Teeth Spacing
Difficulty Opening Mouth
Teeth Sensitivity
Difficulty Closing Mouth
Changes with your Bite
Noises in Jaw Joints
Morning Hoarseness
Ear Stuffiness
Dry Mouth Upon Waking
Fatigue
Significant Daytime Drowsiness
Difficulty Falling Asleep
Affect Sleep of Others
Tossing and Turning Frequently
Short of Breath when Waking
Repeated Awakening
Told "I stop breathing" During Sleep
Feeling Un-refreshed in the Morning
Night-Time Choking Spells
Morning Headaches
Unable to Tolerate C-Pap
Nighttime Urination
Tooth Grinding
Night Sweats
Teeth Crowding
Vivid Dreams
Frequent Heavy Snoring
Sore Jaw Upon Waking
Acid Indigestion
Any Other Symptoms not listed above

Allergic Reactions

Please check any and all medications or substance that have caused an allergic reaction


Current Medications

Please list all medications and supplements (over-the-counter and prescription) you are taking and the reason you take them.

See Attached List

Previous Treatment, Medications and Other Therapies Attempted For The Condition We Are Evaluating

See Attached List

Sleep Conditions

Please select the yes or no answers based on your average sleep experience and/or what a sleep partner has told you

Sleep Position?
Sleep Location?
Bed Partner?
Average hours of sleep per night?
Is it easy to fall asleep?
Average hours of sleep per day?
Do you wake often during the night?
Cough, gasps or snorts on waking?
Do you feel rested upon waking?
Observed pauses in breath?
Stopped breathing during sleep?
Have you ever had a sleep test?:
Date:
Result:
Previous Positive Airway Pressure Devices Used?
Do you currently use a PAP Device?
Type:
Previous Oral Appliance?
Type:

Health And Medical History

Are you currently pregnant?
Do you drink 4 or more cups of coffee per day?
Do you smoke tobacco?
Do you consume alcohol or take sedatives?
Do you have trouble breathing through your nose?
Have you had prior orthodontic treatments?
Have you had previous injury to:
How many energy drinks do you drink?

Surgical History

Have you had any of the following:

General Anesthesia
Orthognathic Surgery
Adenoids Removed
Oral Surgery
Tonsils Removed
Removal of Third Molar (Wisdom Teeth)
Jaw Joint Surgery
Other types of surgery:

Additional Health And Medical History

Do you have or have you experienced any of the following

Anemia
Anxiety
Asthma
Bleeding Easily
Birth Defects
Bruising Easily
Cancer of
Chemo
Chronic Fatigue
Cold Hands and Feet
COPD
Depression
Diabetes
Difficulty Concentrating
Difficulty Breathing at Night
Dizziness
Emphysema
Epilepsy
Excessive Thirst
Fainting
Fibromyalgia
Fluid Retention
Frequent Colds/Flu
Frequent Cough
Frequent Ear Infections
Frequent Sore Throat
Awakening from Sleep
Gastroesophogeal Reflux
Glaucoma
Hay Fever
Hearing Impairment
Heart Attack
Heart Disease
Heart Murmur
Heart Pacemaker
Heart Palpitations
Heart Valve Replacement
Hemophilia
Hepatitis
High Blood Pressure
History of Substance Abuse
Huntington's Disease
Hypoglycemia
Insomnia
Intestinal Disorder
Irregular Heartbeat
Kidney Disease
Leukemia
Liver Disease
Low Blood Pressure
Meniere's Disease
Memory Loss
Migraines
Mitral Valve Prolaps
Multiple Sclerosis
Muscle Aches
Muscle Fatigue
Muscle Spasms
Muscular Dystrophy
Neuralgia
Nervous system Disorder
Osteoarthritis
Osteoporosis
Ovarian Cyst
Parkinson's Disease
Poor Circulation
Psychiatric Care
Radiation
Recent Weight Gain
Recent Weight Loss
Rheumatic Fever
Rheumatoid Arthritis
Scarlet Fever
Shortness of Breath
Skin Disorder
Sinus Problems
Slow Healing Sores
Speech Difficulties
Stroke
Swollen or Painful Joints
Thyroid Disease
Tired Muscles
Tuberculosis
Urinary Tract Disorder

History of Symptoms

On what date, or approximate date, did the condition you are seeking treatment for occur?
Are the conditions listed as the reason for visit caused by a motor vehicle accident?
If yes, what conditions:
Date of accident:
Does any family member snore or have sleep apnea?
If yes, explain:

Additional Symptoms

Location (L = Left, R = Right, B = Bilateral)

Severity (M = Mild, Mo = Mod, S = Severe)

Duration (H = Hours, D = Days, W = Weeks

Frequency (O = Occ, F = Freq, C = Constant


Head Pain
Temple Area
Back of Head
Forehead
Top of Head
All of Head

Jaw Pain
Jaw pain with opening
Jaw pain when chewing
Jaw pain at rest

Jaw Joint Sound
Jaw sounds with opening
Jaw sounds when chewing

Jaw Locking
Jaw locks closed
Jaw locks open

Jaw Joint Symptoms
Teeth clenching
Teeth grinding

Eye Related Conditions
Blurred vision
Pain or pressure behind the eyes
Double vision
Extreme sensitivity to light
Eye pain
Wear of glasses or contacts

Ear Related Conditions
Buzzing in ears
Ear Congestion
Ear pain
Hearing Loss
Itchiness/stuffiness
Pain behind the ear
Pain in front of ear
Recurrent ear infections
Ringing in the ear (tinnitus)

Throat Related Conditions
Chronic sore throat
Thyroid enlargement
Difficulty Swallowing
Tightness in throat
Swollen glands
Feeling of foreign object in throat

Neck related Conditions
Limited movement
Numbness in hands/fingers
Neck pain
Swelling in neck

Shoulder Conditions
Pain in Shoulder
Tingling in fingers/hands
Stiffness in Shoulder

Back Conditions
Low Back Pain
Scoliosis
Middle Back Pain
Sciatica
Upper Back Pain

Mouth/Nose Conditions
Chronis Sinusitis
Broken Teeth
Dry Mouth
Biting Cheeks
Frequent Snoring
Burning Tongue

Even if your symptoms are pain related please - Complete this section

1. Daytime Sleepiness Evlauation - Epworth Sleepiness Scale

For the following situations, answer with one of the following numbers: 0 - would never doze 1 - slight chance of dozing 2 - moderate chance of dozing 3 - high chance of dozing

Situation
Score
Situation
Sitting and reading
Sitting and talking to someone
Watching Television
Sitting quietly after a lunch (no alcohol)
Sitting, inactive public place
In a car, while stopped for a few minutes in traffic
As a passenger in a car for an hour without a break
Lying down to rest in the afternoon when circumstances permit
Add Your Score:

2. Nighttime Sleepiness Evaluation

Developed by David White, M.D., Harvard Medical School, Boston, MA

1. Snoring
a) Do you snore on most nights (>3 nights per week)?
b) Is your snoring loud? Can it be heard through a door or wall?
2. Has it ever been reported to you that you stop breathing or gasp during sleep?
3. What is your collar size?
Male:
Female:
4. Do you occasionally fall asleep during the day when:
a) You are busy or active
b) Is your snoring loud? Can it be heard through a door or wall?
5. Have you had or are you being treated for high blood pressure?
Add Lines 1 -5

Patient/ Guardian Signature:
Date:
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