Patient Information

Please email the following information to Professor Rothbart, along with your photos and only those X-rays requested by Professor Rothbart:

1.  Contact Information

  1. Your Name
  2. Complete Home Address
  3. Home Telephone Number (not cellular)
  4. Email address

2.  A complete description of all Your Musculolskeletal (muscle and joint) problem(s):

Although much of the information requested below has already been covered in your initial phone consultation with Professor Rothbart, we still need you to send it to us by email.

Describe in detail your healthcare problems(s) including:

  1. Where it is
  2. When it started
  3. How frequently it occurs [daily, weekly, sporadically etc]
  4. The degree of your disability
  5. What activity aggravates it
  6. What you do to reduce the pain
  7. Prior therapies you have tried in order to relieve your chronic pain
  8. Any other information you feel may be relevant to your problem

3.  Additional Information:

Describe any past injuries

Describe all prior therapies you have tried in order to eliminate your chronic pain

  1. List any drugs you have taken (e.g., pain medication, tranquillizers)
  2. Any history of orthodontic care, lost teeth, dentures or TMJ problems
  3. Any history of visual problems.  Do you wear glasses.  If so, when do you wear your glasses (e.g., all the time, only for reading, only for driving)
  4. ​Any history of heart, lung, kidney or liver problems
  5. Any history of sleeping problems
  6. ​Any history of irritability
  7. ​Your height and weight

4.  Your expectations from therapy