Patient Health Questionnaire


Please fill out our quick Patient Health Questionnaire and someone from our team will be in touch within 1-2 business days. Feel free to contact us here if you have any additional questions.

Patient Information

 


What is the chief complaint for which you are seeking treatment in our office?

 

Headache PainEar PainJaw PainPain When ChewingFacial PainEye PainThroat PainNeck PainShoulder PainBack PainLimited Ability to Open MouthJaw Joint Locking
Jaw Joint NoisesEar CongestionSinus CongestionDizzinessTinnitus (Ringing in the Ears)Muscle TwitchingVision ProblemsKicking or Jerking Leg RepeatedlySwelling in Ankles or FeetMorning HoarsenessDry Mouth Upon WakingFatigue
Difficulty Falling AsleepTossing & Turning FrequentlyRepeated AwakeningFeeling Unrefreshed in MorningSignificant Daytime DrowsinessFrequent Heavy SnoringAffects Sleep of OthersGasping When WakingTold “I Stop Breathing When Sleeping”Night-time Choking SpellsUnable to Tolerate C-PApTooth Grinding

 
 


Additional Comments & Questions

*Please identify any of the above chief complaints if they have been more than 6+ months of chronic pain.
Address

Erb West Dental Providing
Jaw Joint and Airway Solutions
646 Erb St W Unit # 103 Waterloo ON N2T 2K8

Phone

(519) 954-5297

Email

info@jjaws.ca

HOURS

Monday to Thursday:
9:00 AM – 5:00 PM

Friday:
9:00AM – 3:00PM

Questionnaire

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