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 Pain Ear Pain Jaw Pain Pain When Chewing Facial Pain Eye Pain Throat Pain Neck Pain Shoulder Pain Back Pain Limited Ability to Open Mouth Jaw Joint Locking
 Jaw Joint Noises Ear Congestion Sinus Congestion Dizziness Tinnitus (Ringing in the Ears) Muscle Twitching Vision Problems Kicking or Jerking Leg Repeatedly Swelling in Ankles or Feet Morning Hoarseness Dry Mouth Upon Waking Fatigue
 Difficulty Falling Asleep Tossing & Turning Frequently Repeated Awakening Feeling Unrefreshed in Morning Significant Daytime Drowsiness Frequent Heavy Snoring Affects Sleep of Others Gasping When Waking Told “I Stop Breathing When Sleeping” Night-time Choking Spells Unable to Tolerate C-PAp Tooth Grinding

 
 


Additional Comments & Questions

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