TMJSYNDROMEANDMYOFASCIALPAINHEALTHHISTORYQUESTIONNAIRE
Dateof Birth/Age:
Sex: M or F (circleone) SSN orSIN:
Address: City:
State/Province: Zip/Postal Code:
CHIEFCOMPLAINT(S)
1) Describe whatyou think the problem is:
2) What do you think caused this problem?
MEDICAL ANDDENTALHISTORY
1) Are youpresentlyunder thecareof a physicianorhaveyoubeenin thepastyear?YesNo
Physician’s name:
TREATMENT
2)Howwouldyoudescribeyouroverallphysicalhealth? (circleone)PoorAverageExcellent
3)Howwouldyoudescribeyourdentalhealth? (circleone)PoorAverageExcellent
Date of last appointment:
4)Haveyouhad anymajor dentaltreatmentin thelasttwo years?(circleone) YesNo
If yes, please mark procedure(s): Oral Surgery
HISTORYOFINJURYANDTRAUMA
1)Is thereanychildhoodhistoryof falls, acidents of injury tothefaceof head?YesNo
Describe:
2)Is thereanyrecenthistoryof traumatothehead orface?(Autoaccident,sports injury,facial impact)
YesNoDescribe:
YesNoDescribe:
FACIALPAIN PASTTREATMENT
1)HaveyoueverbeenexaminedforaTMDproblembefore? YesNo
Ifyes,bywhom?When?
Isthisanewproblem?YesNo
5) Haveyou ever had physical therapyfor TMD?YesNoIf yes,by whom? When?
6)Haveyou everreceivedtreatmentforjawproblems?YesNOIf yes,bywhom? When? Whatwasthetreatment?(PleasemarkBelow)
BiteSplint PhysicalTherapyOcclusalAdjustment
CounselingSurgery
Other(Pleaseexplain):
7) Have you ever had injections for your TMD with muscle relaxants (Botox, Flexeril) cortisone or anti-inflammatories?
YesNo YesNo
Howmanydentalappliances haveyouworn? 8) Were these appliances effective? Yes No
CURRENTSTRESSFACTORS(PLEASEMARKEACHFACTORTHATAPPLIESTOYOU)
DeathofaSpouseMajorIllnessorInjuryMajorHealthChangeinFamily
BusinessAdjustmentDivorcePendingMarriage FinancialProblemsPregnancy CareerChange FiredfromWork Debt
DeathofaFamilyMemberNewPersonJoinsFamilyMarital SeparationOther
CURRENTANDPREVIOUSHABITS(PLEASEMARKYOURANSWERTOEACHQUESTION)
1)Do youclenchyourteethtogetherunderstress?...... Yes No Don’tKnow
2)Do yougrind/clenchyourteethatnight?...... Yes No Don’t Know No Don’t Know No Don’tKnow
Describe:
CURRENTSYMPTOMS(PLEASEMARKEACHSYMPTOMTHATAPPLIES)
A.HEADPAIN,HEADACHES,FACIALPAIN
ForeheadLR TemplesLR
MigraineTypeHeadaches
ClusterHeadachesMaxillarySinus
Headaches(undertheeyes)
OccipitalHeadaches(backofthehead
Hairand/orScalpPainfultoTouch
B.EYE PAIN/EARORBITALPROBLEMS Eye Pain-Above,BeloworBehind BloodshotEyes
BlurringofVision
BulgingAppearancePressureBehindtheEyes
WateringoftheEyes
DroopingoftheEyelids
C. MOUTH,FACE, CHEEK
CHINPROBLEMS
Discomfort
LimitedOpening
Inability toOpen Smoothly
D. TEETHGUMPROBLEMS Clenching,GrindingatNight Loosenessand/orSorenessofBack Teeth
ToothPain
E.JAWJAWJOINT(TMD)PROBLEMS
Clicking,PoppingJawJoints
JawLocking Opened orClosed Painin CheekMuscles
UncontrollableJaw/
Tongue Movements
F. PAIN, EARPROBLEMS, POSTURALIMBALANCES
Hissing, Buzzing, or Ringing Sounds
Ear Pain without Infection
Clogged, Stuffy, Itchy Ears
Balance Problems – “Vertigo”
Diminished Hearing
G. NECKSHOULDERPAIN
Armand FingerTingling,Numbness,Pain
Neck Pain
Tired,SoreNeckMuscle Back Pain,Upperand Lower Shoulder Aches
H.THROAT PROBLEMS
TightnessofThroat
SoreThroat
I.OTHERPAIN
CURRENTMEDICATIONS/APPLIANCES/TREATMENTSBEINGUSED
NOPAINMODERATEPAINSEVEREPAIN
1)DegreeofcurrentTMDpain:012345678910
2) FrequencyofTMDpain:DailyWeeklyMonthlySemi-Annually
Howlongdoesitlast? Whatmakesitworse?
YesNoIfso,whattype?
Howlong?
YesNo
5) Areyouawareofanythingthatmakesyourpainworse?YesNoIfyes,what?
6)Doesyourjawmakenoise?YesNoIfso,whenandhow? Right Clicking/Popping Grinding Other Clicking/Popping Grinding Other
7) Doesyourjawlockopen?YesNo
8) Hasyourjaweverlockedclosedorpartlyclosed? YesNo
9)Haveanydentalappliancesbeenprescribed? Yes No
If yes,bywhom?
When? Describe:
Whendoyouwearyourdentalappliances?