My motivation is lower when I am fatigued.

Exercise brings on my fatigue.

I am easily fatigued.

Fatigue interferes with my physical functioning.

Fatigue causes frequent problems for me.

My fatigue prevents sustained physical functioning.

Fatigue interferes with carrying out certain duties and responsibilities.

Fatigue is among my most disabling symptoms.

Fatigue interferes with my work, family, or social life.

Which describes your global fatigue with 0 being worst and 10 being normal?

Reflux Symptom lndex

How Do the Following Problems Affect You? 0 = No Problem 5 = Severe Problem

Hoarseness or a problem with your voice

Clearing your throat

Excess throat mucous or postnasal drip

Difficulty swallowing food, liquids or pills

Coughing after you eat or after lying down

Breathing difficulties or choking episodes

Troublesome or annoying cough

Sensations of something sticking in your throat or a lump in your throat

Heartburn, chest pain, indigestion, or stomach acid coming up

Note: A total score of 10 or less is normal. A total score of 13 or more suggests laryngopharyngeal reflux.

lntermittent dysponia - difficulty producing speech

Yes

Maybe

Sialorrhea - hypersalivation

Yes

Maybe

Cervicaldysphagia - difficulty swallowing

Yes

Maybe

Dysgeusia - distorted sense of smell

Yes

Maybe

Halitosis - bad breath

Yes

Maybe

Throat pain

Yes

Maybe

Nasal Obstruction and Symptoms

Scale 0-5, 5 being severe

Nasal congestion or stuffiness

Nasal blockage or obstruction

Trouble breathing through the nose

Unable to get enough air through the nose during exercise

SLEEP, SNORING AND APNEA HISTORY

Do you have problems with insomnia

Yes

Do you sleep well

Yes

Do you dream

Yes

Do you have trouble falling asleep

Yes

Do you have trouble staying asleep

Yes

Do you snore or have you been told you do

Yes

Do you wake up with a headache

Yes

Have you had chronic sleepiness, fatigue or weariness that you can't explain

Yes

Have you fallen asleep during the day against your will

Yes

Have you had to pull off the road while driving due to sleepiness

Yes

Have you been more irritable and short tempered

Yes

Have you felt that your memory and/or intellect is impaired

Yes

About how many times per night do you wake up

What time do you normally go to bed

What time do you get up in the morning

Of the hours you are in bed, about how many hours are you asleep

Would you rate the quality of your sleep as

ln what position do you sleep

Side Right

Side Left

Stomach

Back

Other

Present body weight (kg)

Kg, cm

Pounds, Inches

Have you been told that you stop breathing while asleep

Yes

Have you been diagnosed or treated for a sleep disorder

Yes

Have any immediate family members been diagnosed or treated for a sleep disorder

Yes

Have you ever had an evaluation at a sleep center

Yes

What professional advice or treatment have you received about your snoring or sleep apnea

lf you sought treatment for a sleep disorder, did it help?

Epworth Sleepiness Scale (EPP)

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 affect you.

Use the following scale and choose the most appropriate number for each situation: 0=no chance, 1=slight chance, 2=moderate chance, 3=high chance.

Sitting inactive, in public, theater, meetings, etc

Sitting and talking to someone

Lying down to rest in the afternoon

As a passenger in a car, for an hour, with no break

Sitting quietly after lunch, without alcohol

In a car, stopped in traffic, for a few minutes

CPAP History

If you have not worn a CPAP device, skip this section!

Do you wear a CPAP device successfully during sleeping?

Yes

How many hours per night do you wear your CPAP

Have you tried other therapies for your sleeping disorder?

Yes

If you are unable to wear a CPAP device, please check below the reasons for your difficulty

Mask Leaks

Mask/Device Uncomfortable

Unable to sleep comfortably

Noise disturbs my sleep and/or my bed partner's sleep

Restricts movement during sleep

Does not seem to be effective

Straps/headgear cause discomfort

Pressure on upper lip causes tooth related problems

Latex allergy

Claustrophobia

Other

GENERAL ORAL MYOLOGY QUESTIONS

Has the patient ever sucked his/her thumb or fingers

Yes

lf so, until what age

Has the patient ever used a pacifier

Yes

lf so, until what age

Any other habits present: nail biting, chewing of objects, hair pulling etc

Yes

lf so, please describe

Are there any speech problems present

Yes

Does the patient breathe through his/her mouth while awake

Yes

Does the patient breathe through his/her mouth while asleep

Yes

Has the patient ever undergone a lip and/or tongue tie release procedure

Yes

Was the patient breastfed as an infant

Yes

ls the patient a picky eater

Yes

Does the patient prefer soft foods only

Yes

Does the patient have difficulty swallowing a pill or refuse to swallow pills

Yes

Was the patient born via C-section or naturally

Yes

Were forceps used during delivery

Yes

Were there any birthing complications

Yes

lf so, please describe

ls there a history of orthodontic intervention

Yes

lf so, please describe

Habits and Patterns

Please check those that apply

Usual position of the lips and teeth during the daytime

Open wide

Open slightly

Closed

Lips closed, but jaw position low

Lips closed, but strong chin and lip contraction

Teeth positioned over lower lip

Usual position of the lips, and teeth during sleep

Lips slightly parted

Lips apart, tongue showing

Mouth Breathing

Lips Closed

Usual position of the tongue during the daytime

Protruding between both teeth and lips

Protruding slightly between teeth

Low positioned, pressing against lower teeth

Unobservable, lips closed

Chewing Patterns

Chews with lips open

Chews with excessive lip and chin involvement

Chews with lips closed

Noisy chewing, smacking

Forward-thrusting of tongue during chewing

Reaching out with the tongue to meet the food or liquid

Teeth touch utensil, cup, or glass

Excessive crumbs around mouth and frequent lip licking

Mustache after drinking

Large bites

Fast chewing

Slow chewing

Do you ever have a burning or painful sensation in your mouth

Yes

Do you get popping, clicking, or grinding noises when you open or close

Yes

Do you ever awaken with an awareness of your teeth or jaws?

Yes

Are you aware of clenching during the daytime

Yes

Have you ever been told you grind your teeth during sleep

Yes

Do you have trouble opening your mouth widely

Yes

Does your jaw ever lock open or closed

Yes

Do you feel your bite is different, unstable or uncomfortable

Yes

What professional advice or treatment have you had regarding your TMJ, headaches or pain conditions and problems

lf you sought treatment for a TMJ problem, did it help

Yes

Do you have a night guard

Yes

Do you or have you had any pain in any of the following areas

Jaw

Ear

Face

Neck

Teeth

Head

Other

Do your jaw problems affect your ability to chew

Yes

Has your diet changed due to your jaw problems

Yes

Do your joint noises affect others while eating

Yes

HIT-6 Questionnaire

(evaluation of headache disability)

1. When you have headaches, how often is the pain severe?

2. How often do headaches limit your ability to do usual daily activities including household work, work, school, or social activities?

3. When you have a headache, how often do you wish you could lie down?

4. In the past 4 weeks, how often have you felt too tired to do work or daily activities because of your headaches?

5. In the past 4 weeks, how often have you felt fed up or irritated because of your headaches?

6. In the past 4 weeks, how often did headaches limit your ability to concentrate on work or daily activities?

WHAT ARE THE CHIEF COMPLAINTS FOR WHICH YOU ARE SEEKING TREATMENT?

When did your symptoms first start

Was there a specific incident, accident or injury that seemed to trigger your symptoms

Do your present symptoms affect relationships with family and friends. If so, how

What are your expectations in seeking treatment at this time

What do you see yourself doing, after treatment that you are not able to do now

To better coordinate your treatment, please list the professionals you have consulted regarding your present symptoms. Please be sure to list your primary physician and family dentist. Please indicate if you want us to send them a report from your visit.

I understand and agree to have the indicated professionals I have listed above be sent initial inforrnation and ongoing updates regarding my diagnoses and treatment.

Send records

Do not send my records

I certify that all of the above information contained in the multiple pages of this history form is correct to the best of my knowledge.

Chief Complaint	Order	Frequency	Intensity
Jaw clicking/poping
Jaw joint noises
Jaw locking
Muscle twitching
Limited mouth opening
Dizziness
Headaches
Visual disturbances
Jaw pain
Facial pain
Ear pain
Back pain
Eye pain
Neck pain
Shoulder pain
Pain when chewing
Throat pain
Ear congestion
Sinus congestion
Ringing inthe ears
Fatigue
Frequent heavy snoring
Snoring affecting sleep of others
Significant daytime drowsiness
Stop breathing when sleeping
Difficulty falling asleep
Gasping when waking up
Nighttime choking spells
Feeling unrefreshed upon waking
Morning Hoarseness
Swelling in ankles or feet

Airway / Myology / TMD Assessment

Fatigue Severity Scale (FSS)

Reflux Symptom lndex

Symptoms of LRP

Nasal Obstruction and Symptoms

SLEEP, SNORING AND APNEA HISTORY

Epworth Sleepiness Scale (EPP)

In general EPP scores can be interpreted as follows:

CPAP History

If you are unable to wear a CPAP device, please check below the reasons for your difficulty

GENERAL ORAL MYOLOGY QUESTIONS

Habits and Patterns

Usual position of the lips and teeth during the daytime

Usual position of the lips, and teeth during sleep

Usual position of the tongue during the daytime

Chewing Patterns

TMJ HISTORY

HIT-6 Questionnaire

INSTRUCTIONS : To complete, please circle one answer for each question.

WHAT ARE THE CHIEF COMPLAINTS FOR WHICH YOU ARE SEEKING TREATMENT?

Order

Frequency

Intensity

Family Physician