Center for Family and Cosmetic Dentistry 1 Campus View Blvd., East Columbus, Ohio 43235 (614)-848-5001
TMJ History
HEAD/FACE
Forehead
Temporal
Tension headaches
Migraine headaches
Back of head headaches
EAR
Dizziness
Balance Problems
THROAT
Sore throat without infection
JAW
Jaw pain
Jaw joint pain
Clicking/popping jaw joint
Grating sound in jaw joint
Jaw locks open/shut
EYES
Pain in/around eyes
NECK
Neck pain
Tired/sore neck muscles
Shoulder pain
MOUTH
Abnormal opening
Limited opening
Bad bite
Missing teeth
Excessive mouth breathing
Clench or grind teeth
SLEEP
Do you snore on most night (>3 nights per week)?
Is your snoring loud? Can it be heard through a door or wall?
Has it ever been reported to you that you stop breathing or gasp during your sleep?
What is your collar size?
Male: more than 17 inches
Female: more than 16 inches
Do you occasionally fall asleep during the day when:
You are busy or active?
You are driving or stopped at a light?
Have you had or are you being treated for high blood pressure?
Your Name:
Email:
Phone:
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Street Address:
City:
State:
Zip:
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Sleep disorders
TMJ disorders
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Restorative dentistry
Veneers
Lumineers
Same day crowns
Teeth whitening
Cosmetic bonding
Fillings
Stain removal
Complete family dentistry services
and much more...
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Contact Us
1 Campus View Blvd.
East Columbus,
Ohio 43235
(614) 848-5001
