Dr. Greg Broyde BSc, DDS
Dr. Navdeep Dhaliwal BSc, DDS
526 Riverfront Ave SE
Calgary AB T2G 1E4
Ph: 403 263 9014

Airway / Myology / TMD Assessment

Fatigue Severity Scale (FSS)

Please choose the number between 1 and 7 which you feel best fits the following statements. This refers to your usual way of life within the last week. 1 indicates "strongly disagree" and 7 indicates "strongly agree."


Reflux Symptom lndex

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

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


Symptoms of LRP


Nasal Obstruction and Symptoms

Scale 0-5, 5 being severe


SLEEP, SNORING AND APNEA HISTORY


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.

In general EPP scores can be interpreted as follows:
  • 0-5 Lower Normal Daytime Sleepiness
  • 6-10 Higher Normal Daytime Sleepiness
  • 11-12 Mild Excessive Daytime Sleepiness
  • 13-15 Moderate Excessive Daytime Sleepiness
  • 16-24 Severe Excessive Daytime Sleepiness

CPAP History

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


GENERAL ORAL MYOLOGY QUESTIONS


Habits and Patterns

Please check those that apply


TMJ HISTORY


HIT-6 Questionnaire

(evaluation of headache disability)

This questionnaire was designed to help you describe and communicate the way you feel and what you cannot do because of headaches.

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

(Never = 6, Rarely = 8, Sometimes = 10, Very often = 11, Always = 13)

Class I: 36-49
Class II: 50-55
Class III: 56-59
Class IV: 60 and more
We suggest to talk to your physician for class II or more.



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

Order

Please order your chief complaints by number:
#1 being the 1st or most important,
#2 the 2nd important,
#3 the 3rd less important,
#4, #5, #6... etc.
(please list all)

Frequency

Rate your chief complaints for frequency as follows:
1= Seldom
2= Occasional
3= Frequent
4= Every Day

Intensity

Rate the intensity of each complaint ordered on a scale from 0-10.
0= No Pain to
10= Most severe pain

Chief Complaint Order Frequency Intensity

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.

Family Physician

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.