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TMD
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Registration

Last Name First Name M.I.
Street
City   State Zip
Home Phone     Business Phone
Date of Birth Month Day Year    

Sex  Male Female   Height  Feet Inches    Weight Lbs  

Occupation   Social Security #
Marital Status   Name of Spouse
Spouse's Social Security #
Emergency Contact Relationship
Phone
Are you in good health? Yes   No
Has there been any change in your general health within the past year? Yes   No
My last physical examination was on   Month Year
Are you under the care of a physician? Yes   No
If so, what is the condition being treated? 
Physician's Name
Physician's Street
Physician's City   State   Zip
Physician's Phone #
Have you ever been treated for a serious illness or operation? Yes   No
If so, what was the illness or operation?
Have you been hospitalized or had a serious illness within the past five (5) years? Yes   No
If so, what was the problem?
Do you have or have you had any of the following diseases or problems?
Rheumatic fever of rheumatic heart disease? Yes   No
Congenital heart lesions? Yes   No
Cardiovascular disease (heart trouble, heart attack, coronary insufficiency, coronary occlusion, high blood pressure, ateriosclerosis, stroke)? Yes   No
Do you have pain in chest upon exertion? Yes   No
Are you ever short of breath after mild exercise? Yes   No
Do your ankles swell? Yes   No
Do you get short of breath when you lie down or do you require extra pillows when you sleep? Yes   No
Do you have a cardiac pacemaker? Yes No
Allergy? Yes No
Sinus Trouble? Yes No
Asthma or hay fever? Yes No
Hives or skin rash? Yes No
Fainting spells or seizures? Yes No
Diabetes? Yes No
Do you have to urinate (pass water) more than six times a day? Yes No
Are you thirsty much of the time? Yes No
Does your mouth frequently become dry? Yes No
Hepatitis, jaundice or liver disease? Yes No
Arthritis? Yes No
Inflammatory rheumatism (painful swollen joints)? Yes No
Stomach ulcers? Yes No
Kidney Trouble? Yes No
Tuberculosis? Yes No
Do you have a persistant cough or cough up blood? Yes No
Low blood pressure? Yes No
Veneral disease? Yes No
Other?   
Have you had abnormal bleeding associated with previous extractions, surgery, or trauma? Yes No
Do you bruise easily? Yes No
Have you ever required a blood transfusion? Yes No
If so explain the circumstances
Do you have any blood disorder such as anemia? Yes No
Have you had surgery or x-ray treatment for a tumor, growth, or condition of your head or neck? Yes No
Are you taking any drug or medicine? Yes No
If so, what? 
Are you taking any of the following:
Antibiotics or sulfa drugs? Yes No
Anticoagulants (blood thinners)? Yes No
Medicine for high blood pressure? Yes No
Cortisone (steroids)? Yes No
Tranquilizers? Yes No
Antihistimines? Yes No
Aspirin? Yes No
Insulin, tolbutamide (Orinase) or similar drug? Yes No
Digitalis or drugs for heart trouble? Yes No
Nitroglycerin? Yes No
Oral contraceptive or other hormonal therapy? Yes No
Are you allergic or have you reacted adversely to:
Local anesthetics? Yes No
Penicillin or other antibiotics? Yes No
Sulpha drugs? Yes No
Barbiturates, sedatives, or sleeping pills? Yes No
Aspirin? Yes No
Iodine? Yes No
Codeine? Yes No
Other?  
Have you had any serious trouble associated with any previous dental treatment? Yes No
If so, explain
Do you have any disease, condition, or problem not listed above that you think I should know about? Yes No
If so, explain
Are you employed in any situation which exposes you regularly to x-rays or other ionizing radiation? Yes No
Are you wearing contact lenses? Yes No
If you are a woman are you pregnant? Yes No
If you are a woman do you have any problems associated with your menstrual period? Yes No
If you are a woman are you nursing? Yes No
My last complete dental exam was on   Month Year
What treatment was done at that time?
What prompted you to seek dental care now?
Which dental specialists have you been treated by? 
Registered Dental Hygienist   Orthodontist   Oral Surgeon
Periodontist   Pedodontist   Endodontist   Prosthodontist Other
What's your main complaint concerning your mouth? Please explain.

Do you eat a lot sweets?

 Yes No
About how often do you use dental floss? 
About how often are you troubled with bad breath?
Do your gums bleed when you brush your teeth? Yes No
Are any of your teeth loose? Yes No
Have you noticed gum shrinkage or recession? Yes No
Are you happy with the appearance of your smile? Yes No
Does food get stuck between certain teeth? Yes No
Are any of your teeth sensitive to sweets, biting pressure, hot or cold? Yes No
How many cups do you drink a day of coffee? tea? soda?
Are you happy with the appearance of your smile? Yes No
About how often do you smoke? 
About how often do you drink alcoholic beverages? 
Ever have any unusual lumps, bumps, or discolorations in your mouth or on your head, face or neck? Yes No
Do you have any oral habits like cheek biting, grinding or clenching your teeth while awake or asleep?* Yes No
Did you ever notice clicking, popping or crunching in your jaw joint (TMJ)?* Yes No
Have you ever had surgery of your teeth or jaws? Yes No
Do you have any unreplaced missing teeth? Yes No
Are you a "mouth breather?"* Yes No
What hobbies or activities do you enjoy?
What is your e-mail address?

 

  * If you answered Yes to any of the items marked with a * please continue answering the TMD Screening by following the hyperlink.

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Copyright © 2007 Michael D. Kurtz, DDS
Last modified: October 25, 2007