New Patients: Current Patients: 204.786.6617

Pre-Treatment Questionnaire

If you have any questions or concerns, please call us at 888-272-6982.

For your convenience, we have made our patient questionnaires available online. Please download, print and fill out the following questionnaires and please bring them with you if you are able.

Patient Information | TMJ Questionnaire

For patients who are out of town, please fill out the following online form and submit for pre-treatment consultation to determine if Dr. Fleisher can treat your condition.

Pre-Treatment Questionnaire

    • Name*
    • Email*
    • Phone*
    • Age*
    • Gender*
    • Chief complaint/concern*
    • When did this start?*
    • Last dental visit?
    • Last hygiene (teeth cleaning) visit?
    • How did you hear of us?
    • Are you under the ongoing care of a Medical Practitioner?
    • For what reason?
    • Are you currently taking prescription medication?
    • If so, please list
    • Women, are you pregnant?

TMJ Questionnaire

  • Do you wake with morning headaches?
  • Do you develop a headache about 10 or 11am?
  • Have you been told your headaches are due to tension?
  • Do you find yourself clenching your teeth?
  • Do you have difficulty opening your mouth?
  • Does your jaw get “stuck”, “locked”, or “go out”?
  • Do you have pain around the ears or cheeks?
  • Do you have pain on chewing?
  • Do you have pain on yawning?
  • Do you have pain on wide opening?
  • Does your bite feel uncomfortable or unusual?
  • Have you ever had an injury to your jaw, head, or neck?
  • Have you ever had arthritis?
  • Have you previously been treated for a Temporomandibular (TMJ) Disorder?
  • If so, when and by whom?