TMJ SYNDROME AND MYOFASCIAL PAIN HEALTH HISTORY QUESTIONNAIRE

    CHIEF COMPLAINT(S)

    1) Have you had any major dental treatment in the last two years? (Circle one)

    If yes, please mark procedure(s):

    HISTORY OF INJURY AND TRAUMA

    1) Is there any childhood history of falls, accidents of injury to the face of head?

    2) Is there any recent history of trauma to the head or face? (Auto accident, sports injury, facial impact)

    3) Is there any activity which holds the head or jaw in an imbalanced position? (Phone, swimming, instrument)

    FACIAL PAIN PAST TREATMENT

    1) Have you ever been examined for a TMD problem before?

    Is this a new problem?

    6) Have you ever had a physical therapy for TMD?

    7) Have you ever received treatment for jaw problems?

    What was the treatment? (Please mark Below)

    8) Have you ever had injections for your TMD with muscle relaxants (Botox, Flexeril) cortisone or anti-inflammatories?

    9) Were these appliances effective?

    CURRENT MEDICATIONS

    1) Are you taking medication for the TMD problems?

    2) Are the medications that you take effective?

    CURRENT STRESS FACTORS (PLEASE MARK EACH FACTOR THAT APPLIES TO YOU)

    CURRENT AND PREVIOUS HABITS (PLEASE MARK YOUR ANSWER TO EACH QUESTION)

    CURRENT SYMPTOMS (PLEASE MARK EACH SYMPTOM THAT APPLIES)

    A. HEAD PAIN, HEADACHES, FACIAL PAIN

    Forehead L R

    Temples L R

    Degree of Pain

    1. No Pain
    2. -Mild
    3. -Moderate
    4. -Severe

    Frequency

    1. Daily
    2. Monthly
    3. Yearly

    Time of Day

    1. -Morning
    2. -Afternoon
    3. -Night

    B. EYE PAIN /EAR ORBITAL PROBLEMS

    C. JAW & JAW JOINT (TMD) PROBLEMS

    D. PAIN, EAR PROBLEMS, POSTURAL IMBALAN

    E. NECK & SHOULDER PAIN

    F. THROAT PROBLEMS

    Possible Complications

    Some people may not be able to tolerate the appliances in their mouths. Also, some individuals will develop temporary adverse side effects such as excessive salivation, sore jaw joints, sore teeth and a slight change in their "bite", However, these usually diminish within an hour after appliance removal in the morning. On a rare occasion, a permanent "bite" change may occur due to jaw joint changes and/or tooth movement. Generally, this can be prevented with modifications to the appliance. These complications may or may not be fully reversible once appliance therapy is discontinued. If not, restorative, orthodontic, and/or surgical treatment may be required, for which you are responsible. Oral appliances can wear and break. The rare possibility that these or broken parts from them may be swallowed or aspirated exists. For patients with sleep apnea, the device must be worn nightly. Discontinuation of use is a hazard to your health and can lead to a heart attack, or stroke, and even death. See your prescriber before discontinuing use and for recommendations of alternative therapy such as CPAP and/or surgery.