TMJ SYNDROME AND MYOFASCIAL PAIN HEALTH HISTORY QUESTIONNAIRE Patient Name: Date of Birth/Age: Email: Phone Number: Address: CHIEF COMPLAINT(S) 1) Describe what you think the problem is: 2) What do you think caused this problem? 3) Describe, in order (first to last), what you expect from your treatment: Dentist's name: Date of last appointment: 1) Have you had any major dental treatment in the last two years? (Circle one) YesNo If yes, please mark procedure(s): Orthodontics Periodontics Several days a week Occlusal Adjustment Restorative Date(s) of Third Molar (wisdom tooth) extraction(s): HISTORY OF INJURY AND TRAUMA 1) Is there any childhood history of falls, accidents of injury to the face of head? YesNo Describe: 2) Is there any recent history of trauma to the head or face? (Auto accident, sports injury, facial impact) YesNo 3) Is there any activity which holds the head or jaw in an imbalanced position? (Phone, swimming, instrument)YesNo Describe: 5) Have you ever been sedated (put to sleep) for surgery?Yes If yes, when? No FACIAL PAIN PAST TREATMENT 1) Have you ever been examined for a TMD problem before?YesNo If yes, by whom? When? 2) What was the nature of the problem? (Pain, noise, limitation of movement): Describe: 3) What was the duration of the problem? Months? Years?: Describe: Is this a new problem? YesNo 4) Is your pain in the morning, afternoon, or night? 5) Is the problem getting better, worse or staying the same? 6) Have you ever had a physical therapy for TMD? YesNo if yes, by whom? When? 7) Have you ever received treatment for jaw problems?YesNo if yes, by whom? When? What was the treatment? (Please mark Below) Bite Splint Medication Physical Therapy Occlusal Adjustment Orthodontics Surgery Others: (Please explain): 8) Have you ever had injections for your TMD with muscle relaxants (Botox, Flexeril) cortisone or anti-inflammatories? YesNo if yes, were they effective? YesNo How many dental appliances have you worn? 9) Were these appliances effective?YesNo 10) Is there any additional information that can help us in this area? 11) What makes it worse? 12) What makes it better? CURRENT SYMPTOMS? Does the pain occur on its own or do you need to trigger with function, touching, etc.? If you were to place a Q-tip in your left ear and push forward, does that trigger pain? Can the pain be triggered by touching the skin with a light brush stroke with a Q-tip or pressing on an area with a Q-tip? 1) Are you taking medication for the TMD problems? YesNo How long? Who prescribed the medication? 2) Are the medications that you take effective? YesNo Conditional? CURRENT STRESS FACTORS (PLEASE MARK EACH FACTOR THAT APPLIES TO YOU) Death of a SpouseBusiness AdjustmentMarriage Financial ProblemsFired from WorkDeath of a Family MemberSeparation Other Major Illness or InjuryDivorcePregnancyMarital ReconciliationNew Person Joins Family Major Health Change in FamilyPendingCareer ChangeDebtMarital CURRENT AND PREVIOUS HABITS (PLEASE MARK YOUR ANSWER TO EACH QUESTION) 1) Do you clench your teeth together under stress? YesNo 2) Do you grind/clench your teeth at night? YesNo 3) Do you sleep with an unusual head position? YesNo 4) Are you aware of any habits or activities that may aggravate this condition? YesNo 5) Do you wake up feeling well rested? YesNo 6) Have either of your parents been diagnosed with sleep apnea in the past? YesNo 7) Do you snore? YesNo Describe: CURRENT SYMPTOMS (PLEASE MARK EACH SYMPTOM THAT APPLIES) For items with an option of L and R you must select either L for Left Side, R for Right Side or both L and R for both sides of your face or body if noting Degree of Pain, Frequency, or Time of Day for those items. A. HEAD PAIN, HEADACHES, FACIAL PAIN Degree of Pain 1. Mild 2. Moderate 3. Severe Frequency 1. Daily 2. Monthly 3. Yearly Time of Day 1. Morning 2. Afternoon 3. Night Migraine Type Headaches L L R R Cluster Headaches Maxillary Sinus L L R R 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 / ORBITAL PROBLEMS Blood shot eyes L L R R Pressure behind eyes L L R R Light Sensitivity C. JAW & JAW JOINT (TMD) PROBLEMS Clicking, Popping Jaw Joints L L R R Grating Sounds L L R R Jaw Locking Opened L L R R Jaw Locking Closed L L R R Uncontrollable Jaw/Tongue Movements L L R R Pain in Cheek Muscles L L R R Reduced Mobility and Range of Motion L L R R D. PAIN, EAR PROBLEMS, POSTURAL IMBALANCE Ear Pain without Infection Clogged, Stuffy, Itchy Ears Balance Problems Vertigo Diminished Hearing Hissing, Buzzing, Ringing Sounds E. NECK & SHOULDER PAIN Arm and Finger Tingling, Numbness, Pain L L R R Stiffness L L R R Neck Pain L L R R Tired, Sore Neck Muscle L L R R Back Pain, Upper and Lower L L R R Shoulder Aches L L R R F. THROAT PROBLEMS Swallowing Difficulties Tightness of Throat Sore Throat Voice Fluctuations Signature: Date: 37329
