Name: TMJ & Sleep Therapy Centre
Address: 1245 East University Drive, Granger, Indiana, 46530, US
Telephone: +1-574-203-5599

Patient Health Questionnaire

Step 1 of 9 - Demographic Information

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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Patient Health Questionnaire

Step 1 of 9 - Demographic Information

Demographic Information

Contact Information

Referral Information

Dental Provider Information

Primary Care Provider Information

Additional Provider Information

Current Symptoms

Chief Complaints

Medications

Allergies

Medical History

Medical History, Continued

Currently Experiencing

Symptom History

Additional Information

PHQ-9

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

2. If you checked off any problem on this questionnaire so far...

GAD-7

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

Emergency Contact Information

Signature

Medication	Dosage	Reason for Taking

Treatment/Medication	Doctor/Provider	Approximate Date of Treatment

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

Patient Health Questionnaire

Patient Health Questionnaire

Step 1 of 9 - Demographic Information

Demographic Information

Contact Information

Referral Information

Dental Provider Information

Primary Care Provider Information

Additional Provider Information

Current Symptoms

Chief Complaints

Medications

Allergies

Medical History

Medical History, Continued

Currently Experiencing

Symptom History

Additional Information

PHQ-9

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

2. If you checked off any problem on this questionnaire so far...

GAD-7

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

Emergency Contact Information

Signature

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