PATIENT NAME: DATE: Phone#: On the diagram below, please shade the areas of pain:

Transcription

1 PATIENT INTAKE: TMJ HISTORY PATIENT NAME: DATE: Phone#: On the diagram below, please shade the areas of pain: Date your symptoms began: What symptoms are you experiencing in your jaw? Right or Left: clicking R L popping R L pain R L grating sound R L sticking of joint R L What caused it? What makes it feel better? What makes it feel worse? What treatments have you received? Have you been prescribed a mouth guard, splint, or appliance? Yes Do you still wear it? Yes No No When are symptoms worse? upon awakening later in day other What do the symptoms keep you from doing? Is pain: Achy Pressure Dull Sharp Throbbing Burning Tightness other Does the pain: Wake you up at night? Yes No Increase when you lie down? Yes No Increase when you bend forward? Yes No Increase when you drink hot or cold beverages? Yes No Circle the number below to indicate your present level of pain: (no pain) (unbearable) Is the pain always present? Yes No How often do you have it? 10% 20% 30% 40% 50%60% 70% 80% 90% 100% of day Describe any other symptoms that you associate with the problem:

2 PATIENT INTAKE: TMJ HISTORY Have you had in the PAST: yes no Neck or head surgery? When and why: yes no Whiplash or trauma to your head or neck? When? yes no Shingles on your head or neck? Do you CURRENTLY have: yes no A fever? yes no Nasal congestion or stuffiness? yes no Movement difficulties of your facial muscles, eyes, mouth or tongue? yes no Numbness or tingling of face? yes no Numbness or tingling in hands? R or L yes no Problems with your teeth? Which ones? yes no Swelling over your jaw joint or in your mouth or throat? yes no A certain spot that triggers your pain? Where? yes no Recurrent swelling or tenderness of joints other than in your jaw joint? yes no Morning stiffness in your body, other than with your jaw? yes no Muscle tenderness in your body other than in your head or neck for more than 50% of the day? Where? yes no Inability to open mouth smoothly? R or L Is your problem worse: yes no When swallowing or turning your head? yes no After reading or straining your eyes? yes no Have you ever been unable to open your mouth wide? Explain: yes no Have you ever been unable to close your mouth? Explain: yes no Do you sleep well at night? yes no Does your partner tell you that you grind your teeth at night? How often are you tense, aggravated, stressed, or frustrated during a usual day? always half the day seldom never How often do you feel depressed, sad, blue, or listless during a usual day? always half the day seldom never yes no Do you have suicidal thoughts or thoughts of hurting others? yes no Do you play a wind instrument or/and sing more than 5 hours per week? yes no Are you aware of clenching or grinding your teeth when: (circle) sleeping driving using computer/device at other times What % of day are you teeth touching? % yes no Are you aware of oral habits such as: (circle all that apply) chewing your cheeks chewing objects biting your nails/cuticles tapping your teeth together thrusting out your jaw not aware

3 PATIENT INTAKE: TMJ HISTORY What treatment do you think is need for your problem? Is there anything else you think we should know about your problem? yes no Have you ever been treated for this before? When? Duration: By whom? What treatment? Outcome? yes no Have you noticed any sense of an altered bite, altered jaw posture or altered jaw function during chewing, speech or other mouth movement? yes no Have you noticed any symptoms associated with your ears? (circle) diminished hearing loss ringing, buzzing, hissing roaring sounds sense of pressure pain without infection stuffiness or clogged feeling yes no Have you noticed any symptoms associated with your eyes? eye pain, above, below, or behind eyes bloodshot eyes blurred vision bulging eyes pressure behind eyes watering of eyes drooping of eyelids yes no Have you noticed any symptoms associated with your throat? (circle) swallowing difficulties tightness sore throat voice fluctuations laryngitis frequent coughing/clearing throat tongue pain feeling of foreign object in throat excess salivation pain in hard palate yes no Have you noticed that nay of the symptoms in the head, neck and shoulder region that you are experiencing are increased following speech, chewing, yawning, etc.? yes no Have you noticed any tendency to clench your teeth? yes no Are your teeth sensitive to hot or cold? R L side Molars or front top or bottom yes no Do you have tooth pain? R L side Molars or front top or bottom yes no Do you have a loose tooth? R L side Molars or front top or bottom yes no Do you have dizziness or balance problems or vertigo? yes no Do you breath with an open mouth? yes no Do you have frequent headaches? How often? yes no Do you have cheek pain? Right or Left side yes no Do you have low back pain? Right or Left side yes no Do you have neck pain? Right or Left side Do you have a PAST HISTORY of: yes no Jaw pain? Right or Left side yes no Jaw joint noises? R L yes no Limited opening/movement? R L yes no Jaw sticking/locking/dislocation yes no Stiff/tight or tired jaw? R L

4 PATIENT INTAKE: TMJ HISTORY yes no Painful opening/closing? R L yes no Facial pain/tightness? R L yes no Headaches? yes no Ear pain? R L yes no Stuffiness in ears? R L yes no Tinnitus/ringing in ears? R L yes no Vertigo/dizziness yes no Difficulty swallowing yes no Neck aches/ history of whiplash yes no Decreased range of motion with neck R L yes no Low back pain, chronic R L yes no Recent changes in bite R L yes no Recent injury to head, neck, or jaw R L yes no Eye pain R L yes no Chronic fatigue yes no Disequilibrium/dis-co-ordination yes no Mental confusion yes no Irritability yes no Bell s Palsy R L yes no Trigeminal Neuralgia/Tic douloureux R L To the best of my knowledge the above information is correct and I give permission for a written report to be sent to my referring and treating doctors and dentists if needed. Patient signature: Date: INFORMED CONSENT: A cervical manual chiropractic adjustment can cause bodily harm. This maneuver is not performed in this clinic. I have been informed verbally and now in writing of this risk. Patient signature: Date:

5 patient intake: Dr.Kimberly Bensen ADDITIONAL complaint PATIENT NAME: DATE: Address: City: Zip: Cell phone: Home phone: Social Security #: Age: Birthdate: / / Sex: M F height: weight: Describe your ADDITIONAL Present Complaint. Please check all answers and fill in the blanks where appropriate. Date problem began: / / Describe your problem and how it began: mark an X above on the body picture above where the additional problem(s) is : Rate how severe your pain is (circle corresponding number) 0=none 10=most severe How often are your symptoms present? (Circle corresponding) Constantly Frequently Occasionally Intermittent Describe your current pain/symptoms: Sharp/stabbing Throbbing Achy Dull Soreness Weakness Numbness Shooting Burning Tingling Other Since it began, is your problem: Improving Getting Worse No Change

6 patient intake: Dr.Kimberly Bensen ADDITIONAL complaint What makes the problem better? Walking Lying Down Standing Sitting Movements Exercise Inactivity/rest Other What makes the problem worse: Walking Lying Down Standing Sitting Movements Exercise Inactivity/rest Other Can you perform your daily home activities? Yes Yes with help Not at all Describe your job requirements: Heavy Labor Light labor Mainly sitting Mainly stand Can you perform your work activities? Yes, all activities Only some Not at all Describe your stress level: High Moderate Mild None What treatment have you had for this condition in the past? Surgery medications injections physical therapy chiropractic adjustments What tests have you had for this condition: X-rays MRI Date taken: Scans Other: I certify that the above information AND the information on the past history form is complete and accurate to the best of my knowledge. I agree to notify this doctor immediately whenever I have changes in my health condition in the future. Patient s signature: Date:

7 patient intake: Dr.Kimberly Bensen ADDITIONAL complaint PATIENT NAME: DATE: If you have ever had a listed symptom in the Past, please check that symptom in the Past Column. If you are presently troubled by a particular symptom, check that symptom in the Now Column. KNOWLEDGE OF THESE CONDITIONS MAY INFLUENCE THE TYPE OF TREATMENT/THERAPY YOU RECEIVE. PAST NOW CONDITION PAST NOW CONDITION neck pain depression shoulder pain R or L aortic aneurysm upper arm/elbow pain R or L hand pain R or L wrist pain R or L upper back pain lower back pain upper leg or hip pain R or L lower leg /knee pain R or L ankle or foot pain R or L swelling stiffness of joints visual disturbances convulsions dizziness or vertigo headache jaw pain R or L muscular incoordination tinnitus or ringing in ears rapid heart beat high blood pressure angina heart attack date: stroke date: asthma cancer date: type: tumor type: prostate problems blood disorder emphysema (chronic lung) arthritis rheumatoid arthritis diabetes epilepsy ulcer liver/gallbladder problems kidney stones

8 patient intake: Dr.Kimberly Bensen ADDITIONAL complaint PAST NOW CONDITION PAST NOW CONDITION chest pains loss of appetite anorexia abnormal weight gain / loss dermatitis/eczema/rash chronic cough chronic sinusitis general fatigue irregular menstrual flow hepatitis type: bladder infection kidney disorders type: colitis irritable colon HIV/AIDS hospitalizations / Surgeries: breast soreness or lumps endometriosis or PMS loss of bladder control painful urination frequent urination abdominal pain constipation/irregular bowel habits difficulty in swallowing heartburn or indigestion pregnancy #births: birth control pills medications type: Other: HAS FAMILY MEMBER HAD: lung problems epilepsy lupus cancer date: type: chronic back problems chronic headaches high blood pressure diabetes heart problems rheumatoid arthritis drug or alcohol dependence