This evaluation form collects patient information including name, contact details, and symptoms for a mouthpiece fitting from Professional Network. The form gathers details on the type of mouthpiece needed, signs and symptoms experienced by the patient such as neck pain and headaches, diagnosis, and special instructions. It also records information on the referring member from Professional Network who submitted the evaluation.

1. PROFESSIONAL NETWORK
UA PERFORMANCE MOUTHWEAR
EVALUATION FORM
PATIENT INFORMATION
PATIENT NAME ______________________________________________________
DATE ______________
E-MAIL ______________________________________________
CONTACT PHONE # ______________
MOUTHPIECE STYLE (CHECK ONE)
MANDIBULAR (Bottom Teeth)
ALLOY (Bottom Teeth)
MAXILLARY (Top Teeth - Protection)
SIGNS and SYMPTONS - Check All That Apply
__________Neck Pain __________Back Pain_________Foot Pain
__________Shoulder Pain__________Hip Pain _________Facial/Jaw Pain
__________Elbow Pain __________Knee Pain_________Postural
__________Headaches __________Vertigo _________Tinnitus
Diagnosis / ICD-9 Code ___________
SPECIAL INSTRUCTIONS
______________________________________________________________
______________________________________________________________
PROFESSIONAL NETWORK - Member Information
NAME _________________________________ MEMBER # ___________
ADDRESS ______________________________________________________
CITY ____________________________ STATE _______ ZIP _____________
PHONE _________________ E-MAIL ________________________________
SIGNATURE _______________________________