SCREENING FORMFor Patients with Head, Neck and Facial Pain & Sleep-Related Breathing Disorders/Apnea

Primary headaches or migrainesSnoring/Sleep ApneaDisturbed, restless sleepingCPAP IntoleranceDaytime drowsinessAttention deficit in childrenEaraches, stuffiness or ringingNeck, shoulder, back pain or stiffnessDizzinessPain or soreness in TM jointsClicking or grating sounds in TM jointsLimited mouth openingLocking jaw (opened or closed)Facial or undiagnosed teeth painDifficulty swallowing

Patient InformationName: ______________________________________

Address:_________________________________________________________________________________

Phone: ______________________________________ Referred by: Name: ______________________________________ Phone: ___________________________________ Date: _________________Fax: __________________

__ Exam __ 2nd Opinion __ Send Report __ Call Me

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When your patients experience one or more of thesesymptoms, they should have a thorough evaluationby a dentist trained in TM and Sleep. We will be happy to assist you in diagnosis and treatment forpossible Craniomandibular, Temporomandibularor Sleep-Related Breathing Disorders/Apnea.