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FOR DOCTORS

PATIENT PORTAL

TMJ & Sleep Therapy Centre
TMJ & Sleep Therapy CentreTMJ & Sleep Therapy Centre
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Patient Health Questionnaire

Patient Health Questionnaire

Step 1 of 9 - Demographic Information

11%
  • MM slash DD slash YYYY
  • Demographic Information

  • MM slash DD slash YYYY
  • Contact Information

  • Referral Information

    How did you hear about us?
  • Dental Provider Information

  • Primary Care Provider Information

  • Additional Provider Information

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  • Current Symptoms

  • Chief Complaints

    List your top 5 chief complaints from the list above starting with your most bothersome symptom
  • 0 = no pain to 10 = worst possible pain
    Currently:At its best:At its worst:
  • Date:Location:
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  • Medications

    Please list all medications you are currently taking and the reason you are taking them. Include prescription, over the counter, vitamins, herbs, etc. (Please attach an additional sheet if necessary)
  • MedicationDosageReason for Taking 
  • Max. file size: 50 MB.
  • Treatment/MedicationDoctor/ProviderApproximate Date of Treatment 
  • Allergies

  • Medical History

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  • Medical History, Continued

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  • Currently Experiencing

  • If yes, please indicate all that apply:
  • If yes, please indicate all that apply:
  • ABCDEFGHIJ
  • KLMNOPQRST
  • UVWXYZAABBCCDD
  • EEFFGGHHIIJJKKLLMMNNOO
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  • Symptom History

  • Additional Information

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  • PHQ-9

    Complete this page if you are 12 years of age or older
  • 1. Over the last 2 weeks, how often have you been bothered by any of the following problems?

  • Count the total number of answers you listed for the questions above

  • Please enter a number less than or equal to 7.
  • Please enter a number less than or equal to 7.
  • Please enter a number less than or equal to 7.
  • Please enter a number less than or equal to 7.
  • 2. If you checked off any problem on this questionnaire so far...

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  • GAD-7

    Complete this page if you are 12 years of age or older
  • Over the last 2 weeks, how often have you been bothered by the following problems?

  • Count the total number of answers you listed for the questions above

  • Please enter a number less than or equal to 7.
  • Please enter a number less than or equal to 7.
  • Please enter a number less than or equal to 7.
  • Please enter a number less than or equal to 7.
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  • Emergency Contact Information

    In case of an emergency, please contact:
  • Mark an "X" in the appropriate Information Box(es)
    NameRelationshipMedical InformationFinancial Information 
  • Signature

  • My signature certifies that the information listed on this form is accurate and complete to the best of my knowledge
  • MM slash DD slash YYYY
  • My signature above certifies that the information listed on this form is accurate and complete to the best of my knowledge.
  • MM slash DD slash YYYY
  • This field is for validation purposes and should be left unchanged.
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REQUEST APPOINTMENT

574-968-5166

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TMJ & Sleep Therapy Centre
7221 N. Fir Road
Granger, IN 46530

OFFICE HOURS
Monday......................... 8:00 am - 4:00 pm
Tuesday......................... 8:00 am - 4:00 pm
Wednesday......................... 8:00 am - 4:00 pm
Thursday......................... 8:00 am - 4:00 pm
Friday......................... Closed
Saturday......................... Closed
Sunday......................... Closed
ADDITIONAL LINKS
  • Home
  • Meet The Practice
  • TMD/Head & Facial Pain
  • Sleep Disorders
  • Pediatrics
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  • Workshops
  • Contact Us
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