Patient Health Questionnaire Step 1 of 9 - Demographic Information 11% LinkedInThis field is for validation purposes and should be left unchanged.Today's Date MM slash DD slash YYYY Demographic InformationLast Name*Middle InitialFirst Name*Marital Status Single Married Widowed Separated Divorced AgeDate of Birth* MM slash DD slash YYYY Social Security NumberSex Male Female Prefer Not to Answer Ethnicity American Indian/Alaska Native Asian Black/African American Hispanic/Latino Native Hawaiian/Pacific Islander White Other Decline OccupationResponsible Party/Legal Guardian (if different than patient)Relationship to PatientContact InformationAddress Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Email* EmployerPhone*Phone TypeHomeCellWorkOtherAlternate PhoneAlternate Phone TypeHomeCellWorkOtherReferral InformationHow did you hear about us?Referral Name/SourceReferral Type Doctor Dentist Specialist Patient Dental Provider InformationDental Provider OfficeLast VisitMonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Dentist NameOffice PhoneAddress City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code I authorize communications and consent to release and/or obtain any of my information regarding my treatment with Daniel G. Klauer, DDS including a full report of examination findings, diagnosis, treatment plan and progress report between TMJ & Sleep Therapy Centre and the professional care team listed above.Primary Care Provider InformationPrimary Care Physician OfficeLast VisitMonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Doctor NameOffice PhoneAddress City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code I authorize communications and consent to release and/or obtain any of my information regarding my treatment with Daniel G. Klauer, DDS including a full report of examination findings, diagnosis, treatment plan and progress report between TMJ & Sleep Therapy Centre and the professional care team listed above.Additional Provider InformationAdditional Provider Office (if applicable)Last VisitMonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Doctor NameOffice PhoneAddress City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code I authorize communications and consent to release and/or obtain any of my information regarding my treatment with Daniel G. Klauer, DDS including a full report of examination findings, diagnosis, treatment plan and progress report between TMJ & Sleep Therapy Centre and the professional care team listed above.Additional Provider Office (if applicable)Last VisitMonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Doctor NameOffice PhoneAddress City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code I authorize communications and consent to release and/or obtain any of my information regarding my treatment with Daniel G. Klauer, DDS including a full report of examination findings, diagnosis, treatment plan and progress report between TMJ & Sleep Therapy Centre and the professional care team listed above.Patient Initials* Current SymptomsReason for this appointment Pain Sleep/Airway Orthodontics Other:Please check all symptoms you are currently experiencing: Back Pain Difficulty Closing Mouth Dizziness Dyskinesia Ear Congestion Ear Pain Ear Stuffiness Eye Pain Facial Pain Headache (inside head) Headache (outside head) Jaw Joint Locking Jaw Joint Noises Jaw Pain Limited Ability to Open Muscle Twitching Neck Pain Nerve Pain Numbness Pain When Chewing Shoulder Pain Sinus Congestion Throat Pain Tinnitus (Ringing in Ears) Vision Problems Acid Indigestion Affecting Sleep Partner Difficulty Falling Asleep Dry Mouth Upon Waking Fatigue Feel Unrefreshed in Morning Frequent Heavy Snoring Frequent Tossing & Turning Kicking/Jerking Legs Repeatedly Morning Headaches Morning Hoarseness in Voice Night Sweats Nighttime Choking Spells Nighttime Urination Repeated Awakening Short of Breath Sore Jaw Upon Waking Swelling in Ankles/Feet Teeth Crowding Teeth Grinding Told I Stop Breathing During Sleep Unable to Tolerate CPAP Vivid Dreams Chief ComplaintsList your top 5 chief complaints from the list above starting with your most bothersome symptomChief Complaint #1Back PainDifficulty Closing MouthDizzinessDyskinesiaEar CongestionEar PainEar StuffinessEye PainFacial PainHeadache (inside head)Headache (outside head)Jaw Joint LockingJaw Joint NoisesJaw PainLimited Ability to OpenMuscle TwitchingNeck PainNerve PainNumbnessPain When ChewingShoulder PainSinus CongestionThroat PainTinnitus (Ringing in Ears)Vision ProblemsAcid IndigestionAffecting Sleep PartnerDifficulty Falling AsleepDry Mouth Upon WakingFatigueFeel Unrefreshed in MorningFrequent Heavy SnoringFrequent Tossing & TurningKicking/Jerking Legs RepeatedlyMorning HeadachesMorning Hoarseness in VoiceNight SweatsNighttime Choking SpellsNighttime UrinationRepeated AwakeningShort of BreathSore Jaw Upon WakingSwelling in Ankles/FeetTeeth CrowdingTeeth GrindingTold I Stop Breathing During SleepUnable to Tolerate CPAPVivid DreamsChief Complaint #2Back PainDifficulty Closing MouthDizzinessDyskinesiaEar CongestionEar PainEar StuffinessEye PainFacial PainHeadache (inside head)Headache (outside head)Jaw Joint LockingJaw Joint NoisesJaw PainLimited Ability to OpenMuscle TwitchingNeck PainNerve PainNumbnessPain When ChewingShoulder PainSinus CongestionThroat PainTinnitus (Ringing in Ears)Vision ProblemsAcid IndigestionAffecting Sleep PartnerDifficulty Falling AsleepDry Mouth Upon WakingFatigueFeel Unrefreshed in MorningFrequent Heavy SnoringFrequent Tossing & TurningKicking/Jerking Legs RepeatedlyMorning HeadachesMorning Hoarseness in VoiceNight SweatsNighttime Choking SpellsNighttime UrinationRepeated AwakeningShort of BreathSore Jaw Upon WakingSwelling in Ankles/FeetTeeth CrowdingTeeth GrindingTold I Stop Breathing During SleepUnable to Tolerate CPAPVivid DreamsChief Complaint #3Back PainDifficulty Closing MouthDizzinessDyskinesiaEar CongestionEar PainEar StuffinessEye PainFacial PainHeadache (inside head)Headache (outside head)Jaw Joint LockingJaw Joint NoisesJaw PainLimited Ability to OpenMuscle TwitchingNeck PainNerve PainNumbnessPain When ChewingShoulder PainSinus CongestionThroat PainTinnitus (Ringing in Ears)Vision ProblemsAcid IndigestionAffecting Sleep PartnerDifficulty Falling AsleepDry Mouth Upon WakingFatigueFeel Unrefreshed in MorningFrequent Heavy SnoringFrequent Tossing & TurningKicking/Jerking Legs RepeatedlyMorning HeadachesMorning Hoarseness in VoiceNight SweatsNighttime Choking SpellsNighttime UrinationRepeated AwakeningShort of BreathSore Jaw Upon WakingSwelling in Ankles/FeetTeeth CrowdingTeeth GrindingTold I Stop Breathing During SleepUnable to Tolerate CPAPVivid DreamsChief Complaint #4Back PainDifficulty Closing MouthDizzinessDyskinesiaEar CongestionEar PainEar StuffinessEye PainFacial PainHeadache (inside head)Headache (outside head)Jaw Joint LockingJaw Joint NoisesJaw PainLimited Ability to OpenMuscle TwitchingNeck PainNerve PainNumbnessPain When ChewingShoulder PainSinus CongestionThroat PainTinnitus (Ringing in Ears)Vision ProblemsAcid IndigestionAffecting Sleep PartnerDifficulty Falling AsleepDry Mouth Upon WakingFatigueFeel Unrefreshed in MorningFrequent Heavy SnoringFrequent Tossing & TurningKicking/Jerking Legs RepeatedlyMorning HeadachesMorning Hoarseness in VoiceNight SweatsNighttime Choking SpellsNighttime UrinationRepeated AwakeningShort of BreathSore Jaw Upon WakingSwelling in Ankles/FeetTeeth CrowdingTeeth GrindingTold I Stop Breathing During SleepUnable to Tolerate CPAPVivid DreamsChief Complaint #5Back PainDifficulty Closing MouthDizzinessDyskinesiaEar CongestionEar PainEar StuffinessEye PainFacial PainHeadache (inside head)Headache (outside head)Jaw Joint LockingJaw Joint NoisesJaw PainLimited Ability to OpenMuscle TwitchingNeck PainNerve PainNumbnessPain When ChewingShoulder PainSinus CongestionThroat PainTinnitus (Ringing in Ears)Vision ProblemsAcid IndigestionAffecting Sleep PartnerDifficulty Falling AsleepDry Mouth Upon WakingFatigueFeel Unrefreshed in MorningFrequent Heavy SnoringFrequent Tossing & TurningKicking/Jerking Legs RepeatedlyMorning HeadachesMorning Hoarseness in VoiceNight SweatsNighttime Choking SpellsNighttime UrinationRepeated AwakeningShort of BreathSore Jaw Upon WakingSwelling in Ankles/FeetTeeth CrowdingTeeth GrindingTold I Stop Breathing During SleepUnable to Tolerate CPAPVivid DreamsWhat is your level of head, neck, and facial pain?0 = no pain to 10 = worst possible painCurrently:At its best:At its worst:What results are you seeking from treatment?Please check any dental symptoms that you are currently experiencing: Changes in Bite Dental Changes Teeth Crowding Teeth Sensitivity Teeth Spacing None Any symptoms not listed above?In which position do you sleep? Back Side Stomach Varies Where do you sleep? Bed Couch Chair Other Do you have a bed partner? Yes No Is it easy for you to fall asleep? Yes No How many times do you wake during the night?Do you feel rested upon waking? Yes No Has anyone ever told you that you stop breathing during sleep? Yes No Have you ever had a sleep study? Yes No If yes:Date:Location:Patient Initials* MedicationsPlease list all medications you are currently taking and the reason you are taking them. Include prescription, over the counter, vitamins, herbs, etc. (Please attach an additional sheet if necessary)MedicationDosageReason for Taking Upload Separate Document with Medications Not Listed AboveMax. file size: 50 MB. Previous treatments/medications for the condition we are evaluating:Treatment/MedicationDoctor/ProviderApproximate Date of Treatment TMJ & Sleep Therapy Centre has my permission to obtain my complete medication history, including electronic prescription submissionAllergiesPlease check any and all medications or substances that have caused an allergic reaction: Anesthetics Antibiotics Aspirin Barbiturates Codeine Iodine Latex Metals Penicillin Plastic Sedatives Sulfa OtherMedical HistoryHave you had prior orthodontic treatment? Yes No Have you had sustained injury to: Head Face Neck Teeth OtherIf you experienced an injury listed above, please provide a brief explanationPlease indicate if you have had any of the following: General Anesthesia Adenoids Removed Tonsils Removed Jaw Joint Surgery Orthognathic Surgery Oral Surgery Removal of Wisdom Teeth Nasal Surgery Other SurgeriesDo you have trouble breathing through your nose? Yes No Are you currently pregnant? Yes No Do you drink 4 or more cups of coffee per day? Yes No Do you smoke tobacco? Yes No Do you consume alcohol? Yes No If yes: Habitually Socially Do you take any sedatives/medications/supplements to help yourself fall asleep at night? Yes No If yes, what?Patient Initials* Medical History, ContinuedHave you ever experienced: (Optional - check applicable) Physical Abuse Verbal Abuse Emotional Abuse Sexual Abuse None If yes, please explain (Optional)Do you have or have you experienced any of the following? AIDS/HIV Anemia Anxiety Asthma Birth Defects Bleeding Easily Bruising Easily Cancer Chronic Fatigue Cold Hands and Feet Depression Diabetes Difficulty Breathing at Night Difficulty Concentrating Dizziness Eating Disorder Ehlers-Danlos Syndrome (EDS) Emphysema Epilepsy Excessive Thirst Fainting Fibromyalgia Fluid Retention Frequent Awakening at Night Frequent Colds/Flus Frequent Cough Frequent Ear Infections Frequent Sore Throat Gastroesophageal Reflux (GERD) Glaucoma Hay Fever Hearing Impairment Heart Disorder/Heart Attack Heart Murmur Heart Pacemaker Heart Palpitations Heart Valve Replacement Hemophilia Hepatitis High Blood Pressure History of Substance Abuse Huntington’s Disease Hypoglycemia Insomnia Intestinal Disorder Irregular Heartbeat Kidney Disease Leukemia Liver Disease Low Blood Pressure Memory Loss Meniere’s Disease Migraines Mitral Valve Prolapse Muscle Aches Muscular Dystrophy Muscle Fatigue Muscle Spasms Muscle Tremors Multiple Sclerosis Nervous System Disorder Neuralgia Osteoarthritis Osteoporosis Ovarian Cyst Parkinson’s Disease Poor Circulation Postural Orthostatic Tachycardia Syndrome (POTS) Psychiatric Care Recent Weight Gain Recent Weight Loss Rheumatoid Arthritis Rheumatoid Fever Scarlet Fever Seizures Shortness of Breath Significant Daytime Drowsiness Sinus Problems Skin Disorder Slow Healing Sores Sleep Apnea Speech Difficulties Stroke Swollen, Stiff, or Painful Joints Thyroid Problem Tired Muscles Tuberculosis Urinary Tract Disorder Does your family have a history of similar conditions, symptoms, or diseases? Yes No If yes, who?Have you been prescribed a CPAP? Yes No Do you use it as prescribed? Yes No Have you had a previous oral appliance, mouthguard, splint, retainer? Yes No Do you use it as prescribed? Yes No How many hours of sleep, on average, do you get per night?How many hours of sleep, on average, during the day?Do you ever cough, gasp, or snort upon waking? Yes No Patient Initials* Currently ExperiencingAre you currently experiencing head pain? Yes No If yes, please indicate all that apply: Temple Area (Temporal) Back of Head (Occipital) Forehead (Frontal) Top of Head (Parietal) General Head Pain Where is your temporal pain located? Left Right Bilateral How long have you experienced temporal pain? Recent Chronic (over 6 mo.) What is the severity of your temporal pain? Mild Moderate Severe What is the duration of your temporal pain? Minutes Hours Days What is the frequency of your temporal pain? Occasional Frequent Constant Where is your occipital pain located? Left Right Bilateral How long have you experienced occipital pain? Recent Chronic (over 6 mo.) What is the severity of your occipital pain? Mild Moderate Severe What is the duration of your occipital pain? Minutes Hours Days What is the frequency of your occipital pain? Occasional Frequent Constant Where is your frontal pain located? Left Right Bilateral How long have you experienced frontal pain? Recent Chronic (over 6 mo.) What is the severity of your frontal pain? Mild Moderate Severe What is the duration of your frontal pain? Minutes Hours Days What is the frequency of your frontal pain? Occasional Frequent Constant Where is your parietal pain located? Left Right Bilateral How long have you experienced parietal pain? Recent Chronic (over 6 mo.) What is the severity of your parietal pain? Mild Moderate Severe What is the duration of your parietal pain? Minutes Hours Days What is the frequency of your parietal pain? Occasional Frequent Constant Where is your general head pain located? Left Right Bilateral How long have you experienced general head pain? Recent Chronic (over 6 mo.) What is the severity of your general head pain? Mild Moderate Severe What is the duration of your general head pain? Minutes Hours Days What is the frequency of your general head pain? Occasional Frequent Constant Are you currently experiencing jaw conditions?If yes, please indicate all that apply: Yes No Jaw pain with opening Left Right Jaw pain when chewing Left Right Jaw pain at rest Left Right Jaw sounds with opening Left Right Jaw sounds when chewing Left Right Jaw sounds at rest Left Right Please indicate if you have had any of the following: Jaw Locks Closed Jaw Locks Open Daytime Teeth Clenching/Grinding Nighttime Clenching/Grinding Blurred Vision Double Vision Pain/Pressure behind eyes Extreme Sensitivity to light Wear Glasses or Contact Lenses Are you currently experiencing any ear related conditions?If yes, please indicate all that apply: Yes No Ear Congestion Left Right Ear Pain Left Right Hearing Loss Left Right Itchiness or Stuffiness in Ears Left Right Pain Behind the Ear Left Right Pain in Front of the Ear Left Right Recurrent Ear Infections Left Right Ringing in the Ear Left Right Please indicate your areas of pain by identifying the applicable letters from the body and head diagrams above and labeling with the appropriate numbers 1-3ABCDEFGHIJKLMNOPQRSTUVWXYZAABBCCDDEEFFGGHHIIJJKKLLMMNNOOPatient Initials* Please indicate if you have had any of the following: Chronic Sore Throat Difficulty Swallowing Swollen Gland Thyroid Enlargement Tightness in Throat Constant Feeling of Foreign Object in Throat Limited Movement of Neck Neck Pain Numbness in hands/fingers Swelling in the neck Shoulder Pain Shoulder Stiffness Tingling in hands or fingers Lower Back Pain Upper Back Pain Middle Back Pain Scoliosis Sciatica Chronic Sinusitis Broken Teeth Dry Mouth Frequent Biting of the Cheek Burning Tongue Sensation Symptom HistoryOn what date, or approximate date, did your condition/symptoms first occur?MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Can you relate your pain/condition to a motor vehicle accident or traumatic injury? Yes No If yes, please explain:Does any family member have a sleep breathing disorder or Obstructive Sleep Apnea? Yes No If yes, who?Does any family member have the same or a similar problem? Yes No If yes, please explain:Additional InformationIs there anything else you would like us to know?Patient Initials* PHQ-9Complete this page if you are 12 years of age or older1. Over the last 2 weeks, how often have you been bothered by any of the following problems?a. Little interest or pleasure in doing things 1 - Not at all 2 - Several days 3 - More than half the days 4 - Nearly every day b. Feeling down, depressed, or hopeless 1 - Not at all 2 - Several days 3 - More than half the days 4 - Nearly every day c. Trouble falling/staying asleep, sleeping too much 1 - Not at all 2 - Several days 3 - More than half the days 4 - Nearly every day d. Feeling tired or having little energy 1 - Not at all 2 - Several days 3 - More than half the days 4 - Nearly every day e. Poor appetite or overeating 1 - Not at all 2 - Several days 3 - More than half the days 4 - Nearly every day f. Feeling bad about yourself or that your are a failure or have let yourself or your family down 1 - Not at all 2 - Several days 3 - More than half the days 4 - Nearly every day g. Trouble concentrating on things, such as reading the newspaper or watching television 1 - Not at all 2 - Several days 3 - More than half the days 4 - Nearly every day h. Moving or speaking so slowly that other people could have noticed. Or the opposite; being so fidgety or restless that you have been moving around a lot more than usual 1 - Not at all 2 - Several days 3 - More than half the days 4 - Nearly every day i. Thoughts that you would be better off dead or of hurting yourself in some way 1 - Not at all 2 - Several days 3 - More than half the days 4 - Nearly every day Count the total number of answers you listed for the questions above0 - Not at allPlease enter a number less than or equal to 7.1 - Several daysPlease enter a number less than or equal to 7.2 - More than half the daysPlease enter a number less than or equal to 7.3 - Nearly every dayPlease enter a number less than or equal to 7.Total2. If you checked off any problem on this questionnaire so far...How difficult have these problems made it for you to do your work, take care of things at home, or get along with other people? Not difficult at all Somewhat difficult Very difficult Extremely difficult Patient Initials* GAD-7Complete this page if you are 12 years of age or olderOver the last 2 weeks, how often have you been bothered by the following problems?1. Feeling nervous, anxious, or on edge 0 - Not at all 1 - Several days 2 - More than half the days 3 - Nearly every day 2. Not being able to stop or control worrying 0 - Not at all 1 - Several days 2 - More than half the days 3 - Nearly every day 3. Worrying too much about different things 0 - Not at all 1 - Several days 2 - More than half the days 3 - Nearly every day 4. Trouble relaxing 0 - Not at all 1 - Several days 2 - More than half the days 3 - Nearly every day 5. Being so restless that it is hard to sit still 0 - Not at all 1 - Several days 2 - More than half the days 3 - Nearly every day 6. Becoming easily annoyed or irritable 0 - Not at all 1 - Several days 2 - More than half the days 3 - Nearly every day 7. Feeling afraid, as if something awful might happen 0 - Not at all 1 - Several days 2 - More than half the days 3 - Nearly every day Count the total number of answers you listed for the questions above0 - Not at allPlease enter a number less than or equal to 7.1 - Several daysPlease enter a number less than or equal to 7.2 - More than half the daysPlease enter a number less than or equal to 7.3 - Nearly every dayPlease enter a number less than or equal to 7.TotalIf you have checked any problems, how difficult have they made it for you to do your work, take care of things at home, or get along with other people? Not at all Somewhat difficult Very difficult Extremely difficult Patient Initials* Emergency Contact InformationIn case of an emergency, please contact:NamePhoneRelationshipAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code The person(s) listed have my approval to access my information:Mark an "X" in the appropriate Information Box(es)NameRelationshipMedical InformationFinancial Information SignatureAcknowledgement* I acknowledge that I have been offered a copy of the Office Privacy Notice and I am familiar with my rights as a patient of Dr. Klauer and TMJ & Sleep Therapy Centre. I understand this practice is Fee for Service Out-of-Network and regardless of my insurance coverage, I am responsible for any charges incurred at the time of my visit.Signature*I understand that by typing my name, I am authorizing my digital signature. My signature certifies that the information listed on this form is accurate and complete to the best of my knowledge.Date* MM slash DD slash YYYY Parent/Guardian SignatureI understand that by typing my name, I am authorizing my digital signature. My signature certifies that the information listed on this form is accurate and complete to the best of my knowledge.Date MM slash DD slash YYYY