TMJ & Sleep Apnea Center of Central Illinois

Welcome to Our Dental Office

We appreciate the confidence you have shown our office by scheduling an appointment for an evaluation. Our mission is to provide you with the highest quality of health care. Good communication is essential for the best treatment results and we welcome any questions or comments you have regarding your treatment.

Before your appointment, please complete the enclosed patient health history form and bring it with you to your initial examination.

The estimated time of your new patient appointment will be 1.5 hours. If you need to cancel or reschedule your appointment, please notify our office at least 24 hours in advance!

If your dentist referred you to our office and you have had a recent panorex x-ray taken (within the last year) please bring a copy with you to your appointment or have a copy forwarded to our office. If you have been referred to our office for sleep apnea please bring a copy of your baseline sleep study or have the sleep center forward a copy prior to your appointment.

Our policy is to collect payment at the time of service. Please be prepared to pay for your initial appointment to our office. Our office accepts cash, check, or credit card at each office visit. We also offer monthly payment plans with no interest for thos who qualify. If you would like an estimated cost for this initial appointment please call our office. We cannot estimate your treatment cost prior to your initial appointment/exam until Dr. Walz has evaluated all your symptoms and we have a diagnosis.

We have two office locations one in Normal and one in East Peoria. See the reverse for a map with directions to both offices or visit our website. Internet maps such as Map Quest or Google can be helpful. However, most GPS systems DO NOT give accurate driving directions to 731 Sabrina Drive in East Peoria. If you need further help with directions please call our office.

Insurance Information

Benefits for treatment of TMJ and Sleep Apnea are customarily filed under your major medical insurance policy. However, some dental plans also provide some coverage for TMJ. We will file your insurance claim for you to your dental or Medical insurance company for possible reimbursement. Once you have been seen in our office we will assist you in finding out what coverage is available under your plan and we can file a predetermination if necessary. )if you would like to find out what coverage is available prior to your first appointment we advise you read your policy carefully and call your insurance carrier to determine what your benefits, limitations or exclusions for TMJ or Sleep Apnea are under your policy. If you are enrolled in an HMO policy it may be required that you see your primary care physician first for a referral to our office. Please contact your plan administrator to see if a referral is needed for coverage.

Medicare Information

Medicare Part B provides coverage for your initial consult and x-ray. We will submit your claim to Medicare, however, payment will be due at the time of service and the patient will be reimbursed from Medicare and their insurance company less any co-pays or deductibles. If you are enrolled in a Medicare replacement plan or Medicare HMO plan it may be required that you see your primary care physician first for a referral to our office. Please contact your plan administrator to see if a referral is needed for coverage.

East Peoria Office

From Peoria: East on 1-74 toward Morton. Take exit #98, Pinecrest Drive. Turn left onto Fahey Hollow Rd and go over the interstate. Turn left onto interstate frontage road, Sabrina Drive. The office is the Ist building on the right. We are the 1st awning/door, Suite A.

From BloomlNormal: Head west on 1-74 toward Peoria. Take exit #98, Pinecrest Drive. Turn right onto Fahey Hollow road. Turn left onto the interstate frontage road, Sabrina Drive. The office is the first building on the right. We are the 1st awning/door, Suite A.

Normal Office

We are located in the ISU area of Bloomington/Normal. From Interstate 55 take Bus-S I South (Main Street) which eventually turns into Kingsley when you past College Ave. Go past Kingsley Jr High on the right then one block south to Dale Street, turn left. Turn immediate left into Dale Kingsley Plaza. Our office is the last suite at the end of the parking lot, suite 4.

We look forward to seeing you at your upcoming appointment. If you need additional directions, please call our office.

Head, Neck & Facial Pain Questionnaire

This questionnaire was designed to provide important facts regarding your past and present medical history. Please take your time to fill out the form accurately as it will assist us in reaching a diagnosis and determine the source of your problem. Please sign and date the bottom of each page.

Personal Information

First Name

Middle Initial

Last

Age

Date of Birth

Gender

Male Female

Street Address

City

State

Zip Code

Home phone

Work Phone

Cell Phone

Employer Name

Address

Occupation

Social Security #

Responsible Party

Who referred you here?

Please include the address of the referring physician

Family Physician

Phone

Street Address

City

State

Zipcode

Family Dentist

Phone

Street Address

City

State

Zipcode

Patient Signature

Date:

Using the guide below please find your chief complaints (the reason you are seeking treatment), list them in order with # 1 being the most important #2 the next important, etc.

Facial Pain

Complaint

Date first started

Frequency of problem

Jaw Pain

Complaint

Date first started

Frequency of problem

Jaw Pain with Chewing

Complaint

Date first started

Frequency of problem

Jaw Joint Noise

Complaint

Date first started

Frequency of problem

Jaw Locking

Complaint

Date first started

Frequency of problem

Limitation in opening

Complaint

Date first started

Frequency of problem

Headaches

Complaint

Date first started

Frequency of problem

Migraines

Complaint

Date first started

Frequency of problem

Eye Pain

Complaint

Date first started

Frequency of problem

Ear Pain

Complaint

Date first started

Frequency of problem

Neck Pain

Complaint

Date first started

Frequency of problem

Shoulder Pain

Complaint

Date first started

Frequency of problem

Poor Sleep

Complaint

Date first started

Frequency of problem

Fatigue

Complaint

Date first started

Frequency of problem

Snoring

Complaint

Date first started

Frequency of problem

Sleep Apnea

Complaint

Date first started

Frequency of problem

Clenching/Grinding

Complaint

Date first started

Frequency of problem

Tooth Sensitivity

Complaint

Date first started

Frequency of problem

Bite Feels Off

Complaint

Date first started

Frequency of problem

Ringing in the Ears

Complaint

Date first started

Frequency of problem

Other

Complaint

Date first started

Frequency of problem

Please list all medications you are currently taking:

Medication and dosage

Date started

Medication and dosage

Date started

Medication and dosage

Date started

Medication and dosage

Date started

Medication and dosage

Date started

Medication and dosage

Date started

Medication and dosage

Date started

Medication and dosage

Date started

Medication and dosage

Date started

Medication and dosage

Date started

Please list any medications to which you may be allergic:

Have you ever been addicted to pain medication?

Yes No

How many caffeinated drinks do you have each day?

Do you smoke?

Yes No

Please list any Health professionals and treatments provided for this problem and all Health professionals you are currently seeing or are scheduled to see.

Practitioner and Specialty

Treatment and date provided

Practitioner and Specialty

Treatment and date provided

Practitioner and Specialty

Treatment and date provided

What do you believe is the cause of your pain or condition?

What makes your symptoms worse? What makes your symptoms better?

Has a doctor or dentist ever diagnosed you with a TMJ disorder?

Yes No

If yes please give date

Have you ever had an injury to your head or neck?

Yes No

Please describe below

Have you ever been in a physically abusive situation?

Yes No

Please describe below

Accident History

If you were involved in an accident or traumatic incident please complete this section:

Date of Accident/Trauma

Please describe the accident or trauma in detail. Include specifics such as where you were seated in the vehicle, if you had direct trauma to any part of your body, if you were struck by an object or part of the vehicle, if you were wearing a seat belt, etc. Indicate any parts of your body that were sore following the accident. Include what hospital you went to, any tests/ x-rays taken or medications given and treatment provided.

Give dates and details of any previous accidents and treatment provided

If you have missed any work due to your accident please give dates

Medical History

(Please indicate dates on questions checked YES)

Adenoids/Tonsils Removed

Yes No

Dates

Anemia

Yes No

Dates

Anxiety

Yes No

Dates

Arteriosclerosis

Yes No

Dates

Asthma

Yes No

Dates

Autoimmune disorders

Yes No

Dates

Bleeding easily

Yes No

Dates

Blood pressure

Yes No

If yes, please select

High Low

Dates

Bruising easily

Yes No

Dates

Cancer

Yes No

Dates

Chemotherapy

Yes No

Dates

Chronic fatigue

Yes No

Dates

Cold hands & feet

Yes No

Dates

Current pregnancy

Yes No

Dates

Depression

Yes No

Dates

Diabetes

Yes No

Dates

Difficulty concentrating

Yes No

Dates

Dizziness

Yes No

Dates

Emphysema

Yes No

Dates

Epilepsy

Yes No

Dates

Excessive thirst

Yes No

Dates

Fibromyalgia

Yes No

Dates

Fluid retention

Yes No

Dates

Frequent cough

Yes No

Dates

Frequent Illnesses

Yes No

Dates

General anesthesia

Yes No

Dates

Glaucoma

Yes No

Dates

Gout

Yes No

Dates

Hay fever

Yes No

Dates

Hearing impairment

Yes No

Dates

Heart murmur

Yes No

Dates

Heart disorder

Yes No

Dates

Heart palpitations

Yes No

Dates

Heart valve replacement

Yes No

Dates

Hemophilia

Yes No

Dates

Hepatitis A B or C

Yes No

Dates

Hypoglycemia

Yes No

Dates

Immune System Disorder

Yes No

Dates

Injury to Head

Yes No

Dates

Injury to Mouth

Yes No

Dates

Injury to Face

Yes No

Dates

Injury to Neck

Yes No

Dates

Injury to Teeth

Yes No

Dates

Insomnia

Yes No

Dates

Intestinal disorders

Yes No

Dates

Jaw joint surgery

Yes No

Dates

Kidney problems

Yes No

Dates

Liver Disease

Yes No

Dates

Lupus

Yes No

Dates

Menstrual cramps

Yes No

Dates

Migraines

Yes No

Dates

Multiple sclerosis

Yes No

Dates

Muscle aches

Yes No

Dates

Muscle shaking (tremors)

Yes No

Dates

Muscle spasms or cramps

Yes No

Dates

Radio buttons

Yes No

Dates

Needing extra pillows to help breathing at night

Yes No

Dates

Nervous system irritability

Yes No

Dates

Nervousness

Yes No

Dates

Neuralgia

Yes No

Dates

Osteoarthritis

Yes No

Dates

Osteoporosis

Yes No

Dates

Ovarian cysts

Yes No

Dates

Parkinson's Disease

Yes No

Dates

Poor circulation

Yes No

Dates

Prior orthodontic treatment

Yes No

Dates

Psychiatric care

Yes No

Dates

Radiation Treatment

Yes No

Dates

Recent dental work

Yes No

Dates

Rheumatic fever

Yes No

Dates

Shortness of breath

Yes No

Dates

Sinus problems

Yes No

Skin disorder

Slow healing sores

Yes No

Dates

Speech difficulties

Yes No

Dates

Stroke

Yes No

Dates

Swollen, stiff or painful joints

Yes No

Dates

Tendency for Frequent Colds

Yes No

Dates

Tendency for Ear Infections

Yes No

Dates

Tendency for Sore Throats

Yes No

Dates

Thyroid Problems

Yes No

Dates

Tired muscles

Yes No

Dates

Tuberculosis

Yes No

Dates

Tumors

Yes No

Dates

Urinary disorders

Yes No

Dates

Wisdom teeth (fhird Molar) extraction

Yes No

Dates

Other Medical/Dental History

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Patient Signature

Date

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