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574-968-5166

TMJ & Sleep Therapy Centre

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Your First Visit
TMD/Head & Facial Pain
Sleep Disorders
Healthy Living

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Your First Visit
Meet the Practice
TMD/Head & Facial Pain
Sleep Disorders
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- Sleep Disorders
- TMD/Head & Facial Pain
Healthy Living
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Contact Us
Request Appointment

Patient Health Questionnaire

Patient Health Questionnaire

Step 1 of 9 - Demographic Information

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Today's Date
MM slash DD slash YYYY
Demographic Information
Last Name*
Middle Initial
First Name*
Marital Status
- Single
- Married
- Widowed
- Separated
- Divorced
Age
Date of Birth*
MM slash DD slash YYYY
Social Security Number
Sex
- Male
- Female
- Prefer Not to Answer
Ethnicity
- American Indian/Alaska Native
- Asian
- Black/African American
- Hispanic/Latino
- Native Hawaiian/Pacific Islander
- White
- Other
- Decline
Occupation
Responsible Party/Legal Guardian (if different than patient)
Relationship to Patient
Contact Information
Address
Street Address Address Line 2 City State ZIP Code
Email*
Employer
Phone*
Phone Type
Alternate Phone
Alternate Phone Type
Referral Information
How did you hear about us?
Referral Name/Source
Referral Type
- Doctor
- Dentist
- Specialist
- Patient
Dental Provider Information
Dental Provider Office
Last Visit
Dentist Name
Office Phone
Address
City State ZIP Code
I authorize communications and consent to release and/or obtain any of my information regarding my treatment with Daniel G. Klauer, DDS including a full report of examination findings, diagnosis, treatment plan and progress report between TMJ & Sleep Therapy Centre and the professional care team listed above.
Primary Care Provider Information
Primary Care Physician Office
Last Visit
Doctor Name
Office Phone
Address
City State ZIP Code
I authorize communications and consent to release and/or obtain any of my information regarding my treatment with Daniel G. Klauer, DDS including a full report of examination findings, diagnosis, treatment plan and progress report between TMJ & Sleep Therapy Centre and the professional care team listed above.
Additional Provider Information
Additional Provider Office (if applicable)
Last Visit
Doctor Name
Office Phone
Address
City State ZIP Code
I authorize communications and consent to release and/or obtain any of my information regarding my treatment with Daniel G. Klauer, DDS including a full report of examination findings, diagnosis, treatment plan and progress report between TMJ & Sleep Therapy Centre and the professional care team listed above.
Additional Provider Office (if applicable)
Last Visit
Doctor Name
Office Phone
Address
City State ZIP Code
I authorize communications and consent to release and/or obtain any of my information regarding my treatment with Daniel G. Klauer, DDS including a full report of examination findings, diagnosis, treatment plan and progress report between TMJ & Sleep Therapy Centre and the professional care team listed above.
Patient Initials*

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Current Symptoms
Reason for this appointment
- Pain
- Sleep/Airway
- Orthodontics
Other:
Please check all symptoms you are currently experiencing:
- Back Pain
- Difficulty Closing Mouth
- Dizziness
- Dyskinesia
- Ear Congestion
- Ear Pain
- Ear Stuffiness
- Eye Pain
- Facial Pain
- Headache (inside head)
- Headache (outside head)
- Jaw Joint Locking
- Jaw Joint Noises
- Jaw Pain
- Limited Ability to Open
- Muscle Twitching
- Neck Pain
- Nerve Pain
- Numbness
- Pain When Chewing
- Shoulder Pain
- Sinus Congestion
- Throat Pain
- Tinnitus (Ringing in Ears)
- Vision Problems
- Acid Indigestion
- Affecting Sleep Partner
- Difficulty Falling Asleep
- Dry Mouth Upon Waking
- Fatigue
- Feel Unrefreshed in Morning
- Frequent Heavy Snoring
- Frequent Tossing & Turning
- Kicking/Jerking Legs Repeatedly
- Morning Headaches
- Morning Hoarseness in Voice
- Night Sweats
- Nighttime Choking Spells
- Nighttime Urination
- Repeated Awakening
- Short of Breath
- Sore Jaw Upon Waking
- Swelling in Ankles/Feet
- Teeth Crowding
- Teeth Grinding
- Told I Stop Breathing During Sleep
- Unable to Tolerate CPAP
- Vivid Dreams
Chief Complaints
List your top 5 chief complaints from the list above starting with your most bothersome symptom
Chief Complaint #1
Chief Complaint #2
Chief Complaint #3
Chief Complaint #4
Chief Complaint #5
What is your level of head, neck, and facial pain?
0 = no pain to 10 = worst possible pain
Currently: At its best: At its worst:
What results are you seeking from treatment?
Please check any dental symptoms that you are currently experiencing:
- Changes in Bite
- Dental Changes
- Teeth Crowding
- Teeth Sensitivity
- Teeth Spacing
- None
Any symptoms not listed above?
In which position do you sleep?
- Back
- Side
- Stomach
- Varies
Where do you sleep?
- Bed
- Couch
- Chair
- Other
Do you have a bed partner?
- Yes
- No
Is it easy for you to fall asleep?
- Yes
- No
How many times do you wake during the night?
Do you feel rested upon waking?
- Yes
- No
Has anyone ever told you that you stop breathing during sleep?
- Yes
- No
Have you ever had a sleep study?
- Yes
- No
If yes:
Date: Location:
Patient Initials*

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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)
Medication Dosage Reason for Taking
Upload Separate Document with Medications Not Listed Above
Max. file size: 50 MB.
Previous treatments/medications for the condition we are evaluating:
Treatment/Medication Doctor/Provider Approximate Date of Treatment
TMJ & Sleep Therapy Centre has my permission to obtain my complete medication history, including electronic prescription submission
Allergies
Please check any and all medications or substances that have caused an allergic reaction:
- Anesthetics
- Antibiotics
- Aspirin
- Barbiturates
- Codeine
- Iodine
- Latex
- Metals
- Penicillin
- Plastic
- Sedatives
- Sulfa
Other
Medical History
Have you had prior orthodontic treatment?
- Yes
- No
Have you had sustained injury to:
- Head
- Face
- Neck
- Teeth
Other
If you experienced an injury listed above, please provide a brief explanation
Please indicate if you have had any of the following:
- General Anesthesia
- Adenoids Removed
- Tonsils Removed
- Jaw Joint Surgery
- Orthognathic Surgery
- Oral Surgery
- Removal of Wisdom Teeth
- Nasal Surgery
Other Surgeries
Do you have trouble breathing through your nose?
- Yes
- No
Are you currently pregnant?
- Yes
- No
Do you drink 4 or more cups of coffee per day?
- Yes
- No
Do you smoke tobacco?
- Yes
- No
Do you consume alcohol?
- Yes
- No
If yes:
- Habitually
- Socially
Do you take any sedatives/medications/supplements to help yourself fall asleep at night?
- Yes
- No
If yes, what?
Patient Initials*

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Medical History, Continued
Have you ever experienced: (Optional - check applicable)
- Physical Abuse
- Verbal Abuse
- Emotional Abuse
- Sexual Abuse
- None
If yes, please explain (Optional)
Do you have or have you experienced any of the following?
- AIDS/HIV
- Anemia
- Anxiety
- Asthma
- Birth Defects
- Bleeding Easily
- Bruising Easily
- Cancer
- Chronic Fatigue
- Cold Hands and Feet
- Depression
- Diabetes
- Difficulty Breathing at Night
- Difficulty Concentrating
- Dizziness
- Eating Disorder
- Ehlers-Danlos Syndrome (EDS)
- Emphysema
- Epilepsy
- Excessive Thirst
- Fainting
- Fibromyalgia
- Fluid Retention
- Frequent Awakening at Night
- Frequent Colds/Flus
- Frequent Cough
- Frequent Ear Infections
- Frequent Sore Throat
- Gastroesophageal Reflux (GERD)
- Glaucoma
- Hay Fever
- Hearing Impairment
- Heart Disorder/Heart Attack
- 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
- Memory Loss
- Meniere’s Disease
- Migraines
- Mitral Valve Prolapse
- Muscle Aches
- Muscular Dystrophy
- Muscle Fatigue
- Muscle Spasms
- Muscle Tremors
- Multiple Sclerosis
- Nervous System Disorder
- Neuralgia
- Osteoarthritis
- Osteoporosis
- Ovarian Cyst
- Parkinson’s Disease
- Poor Circulation
- Postural Orthostatic Tachycardia Syndrome (POTS)
- Psychiatric Care
- Recent Weight Gain
- Recent Weight Loss
- Rheumatoid Arthritis
- Rheumatoid Fever
- Scarlet Fever
- Seizures
- Shortness of Breath
- Significant Daytime Drowsiness
- Sinus Problems
- Skin Disorder
- Slow Healing Sores
- Sleep Apnea
- Speech Difficulties
- Stroke
- Swollen, Stiff, or Painful Joints
- Thyroid Problem
- Tired Muscles
- Tuberculosis
- Urinary Tract Disorder
Does your family have a history of similar conditions, symptoms, or diseases?
- Yes
- No
If yes, who?
Have you been prescribed a CPAP?
- Yes
- No
Do you use it as prescribed?
- Yes
- No
Have you had a previous oral appliance, mouthguard, splint, retainer?
- Yes
- No
Do you use it as prescribed?
- Yes
- No
How many hours of sleep, on average, do you get per night?
How many hours of sleep, on average, during the day?
Do you ever cough, gasp, or snort upon waking?
- Yes
- No
Patient Initials*

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Currently Experiencing
Are you currently experiencing head pain?
- Yes
- No
If yes, please indicate all that apply:
- Temple Area (Temporal)
- Back of Head (Occipital)
- Forehead (Frontal)
- Top of Head (Parietal)
- General Head Pain
Where is your temporal pain located?
- Left
- Right
- Bilateral
How long have you experienced temporal pain?
- Recent
- Chronic (over 6 mo.)
What is the severity of your temporal pain?
- Mild
- Moderate
- Severe
What is the duration of your temporal pain?
- Minutes
- Hours
- Days
What is the frequency of your temporal pain?
- Occasional
- Frequent
- Constant
Where is your occipital pain located?
- Left
- Right
- Bilateral
How long have you experienced occipital pain?
- Recent
- Chronic (over 6 mo.)
What is the severity of your occipital pain?
- Mild
- Moderate
- Severe
What is the duration of your occipital pain?
- Minutes
- Hours
- Days
What is the frequency of your occipital pain?
- Occasional
- Frequent
- Constant
Where is your frontal pain located?
- Left
- Right
- Bilateral
How long have you experienced frontal pain?
- Recent
- Chronic (over 6 mo.)
What is the severity of your frontal pain?
- Mild
- Moderate
- Severe
What is the duration of your frontal pain?
- Minutes
- Hours
- Days
What is the frequency of your frontal pain?
- Occasional
- Frequent
- Constant
Where is your parietal pain located?
- Left
- Right
- Bilateral
How long have you experienced parietal pain?
- Recent
- Chronic (over 6 mo.)
What is the severity of your parietal pain?
- Mild
- Moderate
- Severe
What is the duration of your parietal pain?
- Minutes
- Hours
- Days
What is the frequency of your parietal pain?
- Occasional
- Frequent
- Constant
Where is your general head pain located?
- Left
- Right
- Bilateral
How long have you experienced general head pain?
- Recent
- Chronic (over 6 mo.)
What is the severity of your general head pain?
- Mild
- Moderate
- Severe
What is the duration of your general head pain?
- Minutes
- Hours
- Days
What is the frequency of your general head pain?
- Occasional
- Frequent
- Constant
Are you currently experiencing jaw conditions?
If yes, please indicate all that apply:
- Yes
- No
Jaw pain with opening
- Left
- Right
Jaw pain when chewing
- Left
- Right
Jaw pain at rest
- Left
- Right
Jaw sounds with opening
- Left
- Right
Jaw sounds when chewing
- Left
- Right
Jaw sounds at rest
- Left
- Right
Please indicate if you have had any of the following:
- Jaw Locks Closed
- Jaw Locks Open
- Daytime Teeth Clenching/Grinding
- Nighttime Clenching/Grinding
- Blurred Vision
- Double Vision
- Pain/Pressure behind eyes
- Extreme Sensitivity to light
- Wear Glasses or Contact Lenses
Are you currently experiencing any ear related conditions?
If yes, please indicate all that apply:
- Yes
- No
Ear Congestion
- Left
- Right
Ear Pain
- Left
- Right
Hearing Loss
- Left
- Right
Itchiness or Stuffiness in Ears
- Left
- Right
Pain Behind the Ear
- Left
- Right
Pain in Front of the Ear
- Left
- Right
Recurrent Ear Infections
- Left
- Right
Ringing in the Ear
- Left
- Right
Please indicate your areas of pain by identifying the applicable letters from the body and head diagrams above and labeling with the appropriate numbers 1-3
A B C D E F G H I J
K L M N O P Q R S T
U V W X Y Z AA BB CC DD
EE FF GG HH II JJ KK LL MM NN OO
Patient Initials*

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Please indicate if you have had any of the following:
- Chronic Sore Throat
- Difficulty Swallowing
- Swollen Gland
- Thyroid Enlargement
- Tightness in Throat
- Constant Feeling of Foreign Object in Throat
- Limited Movement of Neck
- Neck Pain
- Numbness in hands/fingers
- Swelling in the neck
- Shoulder Pain
- Shoulder Stiffness
- Tingling in hands or fingers
- Lower Back Pain
- Upper Back Pain
- Middle Back Pain
- Scoliosis
- Sciatica
- Chronic Sinusitis
- Broken Teeth
- Dry Mouth
- Frequent Biting of the Cheek
- Burning Tongue Sensation
Symptom History
On what date, or approximate date, did your condition/symptoms first occur?
Can you relate your pain/condition to a motor vehicle accident or traumatic injury?
- Yes
- No
If yes, please explain:
Does any family member have a sleep breathing disorder or Obstructive Sleep Apnea?
- Yes
- No
If yes, who?
Does any family member have the same or a similar problem?
- Yes
- No
If yes, please explain:
Additional Information
Is there anything else you would like us to know?
Patient Initials*

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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?
a. Little interest or pleasure in doing things
- Not at all
- Several days
- More than half the days
- Nearly every day
b. Feeling down, depressed, or hopeless
- Not at all
- Several days
- More than half the days
- Nearly every day
c. Trouble falling/staying asleep, sleeping too much
- Not at all
- Several days
- More than half the days
- Nearly every day
d. Feeling tired or having little energy
- Not at all
- Several days
- More than half the days
- Nearly every day
e. Poor appetite or overeating
- Not at all
- Several days
- More than half the days
- Nearly every day
f. Feeling bad about yourself or that your are a failure or have let yourself or your family down
- Not at all
- Several days
- More than half the days
- Nearly every day
g. Trouble concentrating on things, such as reading the newspaper or watching television
- Not at all
- Several days
- More than half the days
- Nearly every day
h. Moving or speaking so slowly that other people could have noticed. Or the opposite; being so fidgety or restless that you have been moving around a lot more than usual
- Not at all
- Several days
- More than half the days
- Nearly every day
i. Thoughts that you would be better off dead or of hurting yourself in some way
- Not at all
- Several days
- More than half the days
- Nearly every day
2. If you checked off any problem on this questionnaire so far...
How difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?
- Not difficult at all
- Somewhat difficult
- Very difficult
- Extremely difficult
Patient Initials*

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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?
1. Feeling nervous, anxious, or on edge
- 0 - Not at all
- 1 - Several days
- 2 - More than half the days
- 3 - Nearly every day
2. Not being able to stop or control worrying
- 0 - Not at all
- 1 - Several days
- 2 - More than half the days
- 3 - Nearly every day
3. Worrying too much about different things
- 0 - Not at all
- 1 - Several days
- 2 - More than half the days
- 3 - Nearly every day
4. Trouble relaxing
- 0 - Not at all
- 1 - Several days
- 2 - More than half the days
- 3 - Nearly every day
5. Being so restless that it is hard to sit still
- 0 - Not at all
- 1 - Several days
- 2 - More than half the days
- 3 - Nearly every day
6. Becoming easily annoyed or irritable
- 0 - Not at all
- 1 - Several days
- 2 - More than half the days
- 3 - Nearly every day
7. Feeling afraid, as if something awful might happen
- 0 - Not at all
- 1 - Several days
- 2 - More than half the days
- 3 - Nearly every day
Count the total number of answers you listed for the questions above
0 - Not at all
Please enter a number less than or equal to 7.
1 - Several days
Please enter a number less than or equal to 7.
2 - More than half the days
Please enter a number less than or equal to 7.
3 - Nearly every day
Please enter a number less than or equal to 7.
Total
If you have checked any problems, how difficult have they made it for you to do your work, take care of things at home, or get along with other people?
- Not at all
- Somewhat difficult
- Very difficult
- Extremely difficult
Patient Initials*

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Emergency Contact Information
In case of an emergency, please contact:
Name
Phone
Relationship
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
The person(s) listed have my approval to access my information:
Mark an "X" in the appropriate Information Box(es)
Name Relationship Medical Information Financial Information
Signature
Acknowledgement*
I acknowledge that I have been offered a copy of the Office Privacy Notice and I am familiar with my rights as a patient of Dr. Klauer and TMJ & Sleep Therapy Centre. I understand this practice is Fee for Service Out-of-Network and regardless of my insurance coverage, I am responsible for any charges incurred at the time of my visit.
Signature*
My signature certifies that the information listed on this form is accurate and complete to the best of my knowledge
Date*
MM slash DD slash YYYY
Parent/Guardian Signature
My signature above certifies that the information listed on this form is accurate and complete to the best of my knowledge.
Date
MM slash DD slash YYYY
Comments
This field is for validation purposes and should be left unchanged.

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REQUEST APPOINTMENT

574-968-5166

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

OFFICE HOURS

Monday.........................	8:00 am 5:00 pm
Tuesday.........................	8:00 am 5:00 pm
Wednesday.........................	8:00 am 5:00 pm
Thursday.........................	8:00 am 5:00 pm
Friday.........................	Closed
Saturday.........................	Closed
Sunday.........................	Closed

ADDITIONAL LINKS

Home
Meet The Practice
TMD/Head & Facial Pain
Sleep Disorders
Pediatrics
For Doctors
Workshops
Contact Us

© 2022 TMJ & Sleep Therapy Centre - Dr. Daniel Klauer, DDS

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