Thank you for completing this form before your consultation.
Your responses will help us understand your symptoms and how they may relate to your bite, jaw function, sleep quality, and overall wellbeing.

1. Personal Details

Name

Date of birth:

Phone:

Email

Occupation:

Emergency Contact Name & Number:

2. Medical Background

Are you currently receiving medical treatment or under the care of a doctor? If yes, for what condition(s)?

Are you taking any medications or supplements? Please list:

Do you have any allergies (e.g., medication, latex, food)?

Have you had any major surgeries, head or neck injuries, or accidents?

Do you smoke or vape?

Yes

No

Drink alcohol?

Yes

No

3. Jaw, Bite & Dental Symptoms

Please tick any symptoms you currently experience:

Jaw pain or tenderness

Clenching or grinding teeth (awake or asleep)

Difficulty chewing, speaking, or swallowing

Headaches or facial pain

Neck or shoulder tightness

Clicking, popping, or locking of the jaw

Tooth wear or sensitivity

Bite feels “off” or uneven

Ear pain, blocked ears, or ringing

Limited mouth opening

When did these symptoms begin?

Do they vary in intensity or frequency?

Have you tried any previous treatments (splint, physiotherapy, medication, etc.)?

4. Previous Treatments / Appliances

Have you ever used any of the following?

Bite splint

Night guard

Orthodontic braces or aligners

Botox for TMJ or facial tension

Physiotherapy

Chiropractic care

Sleep study or sleep appliance

Please describe your experience and outcomes:

5. Sleep & Breathing

Please tick any symptoms you currently experience:

Snoring or gasping during sleep

Daytime tiredness or low energy

Morning headaches or jaw tightness

Restless or light sleep

Waking frequently or unrefreshed

Difficulty concentrating or memory issues

Dry mouth or sore throat on waking

Diagnosed with sleep apnoea

Average hours of sleep per night:

Do you use a sleep appliance or CPAP?

Yes

No

If yes, please describe:

6. Mood, Energy & Stress

Please tick any symptoms you currently experience:

Feeling tense or anxious

Fatigue or low motivation

Frequent headaches

Notice symptoms worsen with stress or poor sleep

Difficulty relaxing or “switching off”

Irritability or mood changes

Brain fog or reduced focus

How would you rate your average energy levels (1–10)?

How would you rate your overall stress levels (1–10)?

7. Main Concern & Goals

What is your main reason for today’s consultation?

What would you like to improve most (e.g., comfort, sleep quality, mood, energy)?

On a scale of 1–10, how much are your symptoms affecting your daily life?

8. Additional Information

Is there anything else you would like your clinician to know?

9. Consent & Privacy

I confirm the above information is accurate to the best of my knowledge.

I consent to being contacted regarding my consultation and treatment plan.

I understand that all information provided is confidential.

I understand that treatment may incur costs and that payment is due at the time of treatment.

Name:

Signature:

Date / Time

Wholistic Dentistry’s goal is to provide a high standard of care to patients, improving their quality of life, with a whole body approach to pain management, dental and preventative health treatment.

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