TMJ Pain Questionnaire

Symptoms ( Please Check Any/All Symptoms that you have Experienced)

The initial cause of my problem was: (Ctrl + click to select multiple choice)

Please check off the problems that you experience and the side(s) it relates to. Please select left, right or check both boxes if it applies:

Please indicate other practitioners i.e.: Physicians, Medical Specialists, Chiropractors, Physical Therapists, etc. that you are seeing or have seen for this problem.

My normal day includes:

At the time of the accident, do you remember if you hit your

Please grade your degree of pain since your motor vehicle accident on a scale of 1 – 100.

We do require 48 hours’ notice to change or cancel an appointment. It is our policy to personally confirm your appointment prior to the appointment date. Should we be unable to reach you directly or leave you a voicemail, please return our call to confirm your appointment, or your appointment will be lost.

We are committed to protecting the privacy of our patients’ personal information and to utilizing all personal information in a responsible and professional manner. This document summarizes some of the personal information that we collect, use, and disclose. In addition to the circumstances described in this form, we also collect, use, and disclose personal information when permitted or required by law. We collect information from our patients such as names, home addresses, work addresses, home telephone numbers, work telephone numbers, cell telephone numbers, and email addresses. (Collectively referred to as “Contact Information”) Contact Information is collected and used for the follow purposes: To open and update patient files To invoice patients for dental services, to process credit card payments, or to collect unpaid accounts To send reminders to patients concerning the need for further dental examination or treatment To send patients informational material about our dental practice Contact information is disclosed to third party health benefit providers and insurance companies where the patient has submitted a claim for reimbursement or payment of all or part of the cost of dental treatment or has asked us to submit a claim on the patient’s behalf. Financial information may be collected in order to make arrangements for the payment of dental services. We collect information from our patients about their health history, their family health history, physical condition, and dental treatments (collectively referred to as “Medical Information”). Patients’ Medical Information is collected and used for the purpose of diagnosing dental conditions and providing dental treatment. Patients Medical Information is disclosed: -To third party health benefit providers and insurance companies where the patient has submitted a claim for reimbursement or payment or all or part of the cost of dental treatment or has asked us to submit a claim on their behalf -To other dentists and dental specialists, where we are seeking a second opinion and the patient has consented to us obtaining the second opinion -To other dentists and dental specialists if the patient, with their consent, has been referred by us to the other dentist or dental specialist for treatment -To other dentists and dental specialists where those dentists have asked us, with the consent of the patient, to provide a second opinion -To other health care professionals such as physicians if the patient, with their consent, has been referred by us to the other health care professional for either a second opinion or a treatment If we are ever considering selling all or part of our dental practice, qualified potential purchasers may be granted access as part of the due diligence process to patient information in order to verify information important to the potential sale. If this occurs, we will take steps to ensure that the prospective purchaser safeguards all personal information. Dentists are regulated by the Alberta Dental Association and College which may inspect our records and interview our staff as part of its regulatory activities in the public interest. I authorize Macleod Trail Dental/South Centre Dental to communicate on behalf of myself and all dependents named on my insurance plan, with my insurance company and/or plan administrator with which I may at any time have coverage. I authorize release of personal/financial/dental/medical Information to the same.

I hereby certify that the medical and dental history is accurate and complete, to the best of my knowledge. I consent to the performing of the dental and oral surgery procedures agreed to be necessary or advisable, including the use of local anaesthetics or any drugs as indicated and I will assume responsibility for all fees associated with those procedures. My signature on this form authorizes submission, including electronic submission and direct assignment, where allowed, for claims for dental services provided. I consent to the collection, use and disclosure of personal information as described herein. I have read and understood the foregoing and agree to the terms and conditions stated herein.