Thomas R. Pitts DDS MSD
Arnold C. Pitts DDS MSD
Mark J. Handelin DDS MSD
4786 Caughlin Pkwy. #305
Reno, NV 89519
775-825-3400

Pitts Orthodontics

Patient Information

Responsible Party Information


Additional Persons Responsible for Account

Medical History

Select any of the medical conditions below that you have had or currently have.

Dental History

Medications/Allergies

Please complete the list below for any medications you are currently taking including aspirin, vitamins, herbal supplements:

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Medication Dosage Reason for Taking

Temporomandibular Joint (TMJ) Questionnaire

Do you have jaw joint (TMJ) pain?
;
Do you have TMJ noises when you open and close your mouth?
;
Are the noises:
Have you had TMJ noises in the past?
When did you jaw joint problems begin?
What started your jaw joint problems?
Have you had previous TMJ surgery?
How many procedures?
Have you noticed your jaw alignment or bite changing?
;
Do you get headaches?
;
Are your headaches worse in the:
How many headaches,
,
Do you have neck, shoulder, or back pain?
;
Do you get earaches?
;
Do you get ringing in your ears?
;
Do you get light-headedness or dizziness?

Select the number that best describes your situation:

Rate your jaw function for opening, side to side movement and chewing:

Normal
Function
0 1 2 3 4 5 6 7 8 9 10 No Function
Jaws Frozen

What can you chew:

No restriction
Chew Anything
0 1 2 3 4 5 6 7 8 9 10 Liquids Only
Cannot chew

How much does your jaw problem affect your ability to carry out normal life activities?

No interference
at all
0 1 2 3 4 5 6 7 8 9 10 Totally
disabled

Airway Questionnaire

Do you have difficulty breathing through your nose?
;
Do you breathe through your mouth when you sleep?
;
Do you breathe through your mouth during the day?
;
Do you snore?
;
Are you tired during the day?
;
Do you have sleep apnea?
;
Do you have difficulties sleeping at night?
;
Do you clench and/or grind your teeth at night?
;
Do you wake up with headaches in the morning?
;
Do you wake up at night unable to catch your breath?
;
Do your legs and/or arms jerk at night?
Do you sleep on your:
Do you have high blood pressure?
;
Do you smoke?
;

Acknowledgement of Receipt of Notice of Privacy Practices

Our Privacy Policy can be viewed here. Please review and fill out the information below. You will be given the opportunity to sign the acknowledgement when you visit us for your appointment.

**You May Refuse to Sign This Acknowledgement**

Insurance Information

Patient's relationship to insured:
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Human Verification

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