Did You Know?
Over 40 million Americans Snore
Approximately 1/3 have Sleep Apnea.

Snoring and Apnea can measure your degree of sleepiness.
The following EPWORTH SLEEPINESS SCALE can measure
your degree of sleepiness.  Please indicate the likelihood that you would
 fall asleep in the following situations (scale of 0 to 3).  This refers to
your usual way of life in recent times.  Use the following scale to choose the
most appropriate number for each situation.

0 = would never dose
1 = slight chance of dozing
2 = moderate chance of dozing
3 = high chance of dozing


 
Sitting and reading

Watching television

Sitting inactive in a public place

As a passenger in a car for an hour without a break

Lying down to rest in the afternoon when circumstances permit

Sitting and talking to someone

Sitting quietly after a lunch without alcohol

In a car, while stopped for a few minutes in traffic

If total is greater than 10, please contact your physician.

TMJ Disorder
Patient Self Evaluation Form
Check the Symptoms you have.
 

Front Of Head (Head Aches)
Back Of Head (Head Aches)
Migraines (Head Aches)
Facial Pain (Head Aches)
Sinus Pain (Head Aches)
Eye Pain
Pain Behind Eyes
Blurred Vision
Ear Pain
Hearing Loss R/L
Hissing, Buzzing or Roaring Sounds In The Ears (Tinnitus)
Clogged, Itchy Ears
Balance Problems
Clicking or Popping Jaw Joints (TMJ'S) R/L
Grating Sounds
Jaw Locking, Open or Closed
Jaw Deviates to one side on Opening
Limited Opening
Pain In Either TMJ
Neck Pain
Neck Stiffness
Lack Of Mobility, Reduced Neck Rotation

Have you had Whiplash Injury or a blow to the face?
Yes      No

Which One or Both

 

When

(example)12/12/04

What health professionals have you consulted?
How many of the same professionals have you seen?
(please place the number in the box provided)

Medical Doctor

Physical Therapist

Dentist

Chiropractor

L.M.T. (massage therapy)

Patient Information:

Name:
Address:
Phone#:
EMail Address:
Currently under treatment: Yes No
How did you here about us?
Comments:

Send Info On:

Sleep Apnea A TMJ disorder can rob you of sleep
TMJ Need relief from head, neck and jaw pain?
Could you have TMD and not know it Self-tests show TMD tendencies
Imposter can cause face, neck, jaw pain Snoring, daytime sleepiness point to apnea
Frequent headaches and face pain? Are you dreaming of a good nights sleep?