Click here to Download/Print Form

    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
    Migraine Type Headaches
    Cluster Headaches Maxillary Sinus
    Headaches (under the eyes)
    Occipital Headaches (back of the head with or without shooting pain)
    Hair and/or Scalp Painful to Touch

    B. EYE PAIN /EAR ORBITAL PROBLEMS
    Eye Pain - Above, Below or Behind
    Bloodshot Eyes
    Blurring of Vision
    Drooping of Eyelids
    PressureBehind the Eyes
    Light Sensitivity
    Watering of the Eyes

    C. JAW & JAW JOINT (TMD) PROBLEMS
    Clicking, Popping Jaw Joints
    Grating Sounds
    Jaw Locking Opened
    Jaw Locking Closed
    Uncontrollable Jaw/Tongue Movements
    Pain in Cheek Muscles

    D. PAIN, EAR PROBLEMS, POSTURAL IMBALAN
    Hissing, Buzzing, or Ringing Sounds
    Ear Pain without Infection
    Clogged, Stuffy, Itchy Ears
    Balance Problems Vertigo
    Diminished Hear

    E. NECK & SHOULDER PAIN
    Arm and Finger Tingling, Numbness, Pain
    Reduced Mobility and Range of Motion
    Stiffness
    Neck Pain
    Tired, Sore Neck Muscle
    Back Pain, Upper and Lower
    Shoulder Aches

    F. THROAT PROBLEMS
    Swallowing Difficulties
    Tightness of Throat
    Sore Throat
    Voice Fluctuations