q HEADACHES (MIGRAINES, TENSION, ETC.)q TMJ PAINq TMJ NOISE (CLICKING / POPPING)q LIMITED POPPINGq EAR CONGESTIONq VERTIGO (DIZZINESS)q TINNTUS (RINGING IN THE EARS)q DYSPHAGIA (DIFFICULTY SWALLOWING)q LOOSE TEETHq CLENCHING / BRUXINGq FACIAL PAIN (NONSPECIFIC)q TENDER, SENSITIVE TEETH (PERCUSSION)q DIFFICULTY CHEWINGq CERVICAL PAIN (NECK, SHOULDER, BACK PAIN)q POSTURAL PROBLEMS (IE. FORWARD HEAD POSTURE)q PARESTHESIA OF FINGERTIPS (FINGERTIPS)q THERMAL SENSITIVITY (HOT AND COLD)q TRIGEMINAL NEURALGIA / FIBROMYLAGIAq BELL’S PALSYq NERVOUSNESS / INSOMNIAq SLEEP APNEA

Patient’s Name: ____________________________________

Referred By: ______________________Date:____________

Appointment Date & Time: ___________________________PLEASE CALL 202.363.3399 TO SCHEDULE YOUR PATIENT’S APPOINTMENT.

PLEASE BRING THIS FORM TO YOUR APPOINTMENT.

ADDITIONAL COMMENTS:

Patient Referral THIS PATIENT IS BEING REFERRED FORNEUROMUSCULAR DENTISTRY. THE PATIENT

PRESENTS WITH THE FOLLOWING SYMPTOMS:

DR. SHILA YAZDANI & MICHAEL M. MORTAZIE

3301 NEW MEXICO AVE . NW . SUITE 108 . WASHINGTON DC . 20016 . PHONE 202.363.3399 . FAX 202.363.3397W W W . R E V I V E M E T O D A Y . C O M

WE ARE CONVENIENTLY LOCATED AT THE INTERSECTION OF MACOMB ST. AND NEW MEXICO AVE.

AMERICANUNIVERSITY

NEWARK ST.

MACOMB ST.

LOWELL ST.

KLINGLE ST.NEBRASKA AVE.

EMBASSY PARK DR.

NEW MEXICO AVE.Revive