Please answer below for: What is your chief concern and reason for this visit?
Do you currently experience any of the following symptoms?
Please number your top chief complaints 1-4
Recent is in the last 6 months, Chronic is longer than 6 months
What is your level of head, neck or facial pain: 0 = no pain to 10 = worst possible pain
What are the results you are seeking from treatment?
Sleep Conditions - Please select the yes or no answers based on your average sleep experience and/or what a sleep partner has told you
Please check any and all medications or substance that have caused an allergic reaction
Please list all medications & supplements (over-the-counter & prescription) you are taking and the reason you take them OR
Provide a copy of your personal Medication List
Previous Treatment, Medications and Other Therapies Attempted For The Condition We Are Evaluating
Health And Medical History
Have you sustained injury to:
Surgical History-Have you had any of the following:
Medical History – Patient and Family
Do you have or have experienced any of the following?
Additional Symptoms – HEAD PAIN Please complete for all that apply:
For the below categories, please indicate L or R where applicable
For the below categories, please respond with Yes or No ….DO NOT LEAVE BLANK
Please fully complete both sections 1. and 2. below
1. DAYTIME SLEEPINESS EVLAUATION - EPWORTH SLEEPINESS SCALE
For the following situations, answer with one of the following numbers:
0 - would never doze 1 - slight chance of dozing 2 - moderate chance of dozing 3 - high chance of dozing
2. NIGHTTIME SLEEPINESS EVALUATION
I authorize the release of all examination findings and diagnosis, report and treatment plans, etc., to any referring
or treating health care provider. I additionally authorize the release of any medical information to insurance
companies, third party billing companies, or for legal documentation to process claims. I understand that I am
responsible for all charges incurred for my treatment regardless of insurance covers