TMJ QUESTIONNAIRE. TMJ 1 of 4. Name: Date: Primary Care Physician Name and Phone #: Primary Care Physician
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2 TMJ QUESTIONNAIRE Name: Date: Primary Care Physician Name and Phone #: Primary Care Physician I. MEDICAL/ DENTAL HISTORY A. General Health: 1. Physical Emotional.. B. Do you have a personal physician?... C. Are you currently under the care of a physician?... D. Have you ever been seriously ill?... E. Have you been hospitalized in the past 5 years?... F. Have you ever had a major operation?... G. Women: Are you pregnant?... H. Has there been any change in your general health in the last year?... I. Has there been a major weight loss, without dieting, in recent months?... J. Worried about receiving medical/ dental treatment?... K. Have you now, or in the past, experienced any of the following medical conditions:... Allergies Addiction Anemia (low blood cell count) Arthritis Asthma Arteriosclerosis Bleeding Problems Good Fair Poor Good Fair Poor Blood Diseases Blood Pressure high Blood Pressure low Blood Transfusions Bone Disorder Breathing or Lung Disorder Cancer Chronic pain condition Diabetes Dizziness Drug/substance abuse Epilepsy Endocrine problems Female problems Fibromyalgia Gastrointestinal (GI) problems (ulcers) Genitourinary problems GERD (Acid Reflux) Heart Disease Hearing disorder, ringing ears Hepatitis HIV/AIDS/ARC (circle) Jaundice Kidney Disease Latex allergy Migraine headaches Musculo-skeletal disorder Neurological disorder Psychiatric disorder Rheumatic fever Sleep disturbance (snoring, night gasping) Stroke Venereal Disease OTHER L. Medications currently taken by the patient? ne Antibiotics TMJ 1 of 4
3 Birth control pills/hormones Bisphosphonates (Fosamax, Didronel, Boniva, Aredia, Actonel, Skelid, and Zometa, etc.) Diet Pills (diuretics) Heart Pills (digitalis, etc.) Insulin Muscle Relaxants (valium, etc.) Pain Pills (Demerol, codeine, etc.) Sleeping pills (barbiturates) Tranquilizers or Antidepressants (valium, etc.) OTHER M. Allergies to medical and/or food: ne Antibiotics Dairy Products Dental anesthetics Dyes in foods Metals Pain pills Wheat, cereals, gluten OTHER II. CRANIOFACIAL SYMPTOMS OF THE HEAD, NECK AND FACE Fill in the appropriate response square indicating whether or not you currently have, or previously had, the following conditions or symptoms, and identify which side, right side R of L where appropriate: of both sides are involved, mark right and left sides. Current Condition 1. Bleeding gums and/or gum disease? 2. Crowns on teeth and/or caps? 3. Do you chew gum regularly? 4. Do you feel that your bite closed? 5. Do you feel that there is not enough room for your tongue? 6. Missing back teeth with no replacement? 7. Oral Surgery? 8. Orthodontic treatment? 9. Periodontal disease (pyrrohea)? 10. Sore or painful teeth? 11. Teeth sensitive to cold and/or hot? 12. Teeth badly worn? 13. Teeth have been ground by dentist? 14. Teeth feel very loose? 15. Teeth extracted within the past three years? 16. TMJ (jaw joint) treatment? 17. Treated for a bad bite? 18. Wisdom teeth removed? 19. Do you have frequent canker sores or cold sores? A. CRANIOFACIAL PAIN 20. Do you have generalized facial pain? 21. On which side is there constant or recurring pain? Which Side? 22. Does the pain or discomfort disturb you sleep? 23. Would you describe the pain as a dull, aching sensation? 24. Would you describe the pain as stabbing, sharp, severe sensation? 25. Do you suffer from chronic headache? 26. Do you ever have migraine headaches? 27. Do you have tension headaches? 28. Headaches in the temples? 29. Headaches in the back of the head? 30. Are there times when you notice that the pain or problems are less or gone completely? 31. Do you have pain in teeth on awakening? 32. Do your teeth hurt from clenching or chewing? 33. Does your jaw ache when you chew? 34. Does your jaw hurt when you open wide or take a big bite? 35. Does it now hurt to open wide? 36. Do you have ear pain? 37. Do you have pain in front of the ears? 38. Is the degree of pain same in morning as evenings? 39. Do you have chronic stiff neck? 40. Do you have neckaches (neck pain)? 41. Have you ever had chronic shoulder or back pain? 42. When are your symptoms worse: Upon rising in the morning? At work? At the end of the workday? At home? At school? 43. Have you ever been treated for pain? 44. Have you ever had injections or nerve blocks for pain? 45. Did any of the injections bring relief from pain? 46. Have you ever been operated on to relieve pain? 47. Did the operation bring relief from pain? 48. How often do you take medicine for the relief of pain? Never Seldom (a few times a year) Occasionally (once a month) Often (weekly) Frequently (daily) B. BREATHING PROBLEMS 49. Allergies? 50. Does your nose feel stuffy when you don t have a cold? 51. Does your nose run when you TMJ 2 of 4
4 don t have a cold? 52. Sinus problems? 53. Do you snore? 54. Mouth breather? 55. Do you have sleep apnea? C. EYE PROBLEMS 56. Pain in, around, or behind eyes? 57. Eyesight blurs? 58. Eyelid tics (twitches)? 59. Eyes blink excessively? 60. Do your eyes water most of the time (tearing)? D. EAR PROBLEMS 61. Earaches or ear pain? 62. Hearing loss? 63. Grating noise in ears (like sand particles)? 64. Itchiness in ears? 65. Stuffiness in ears? 66. Ringing, hissing, or buzzing sounds in ears? 67. Whooshing or throbbing sound in ears? E. EQUILIBRIUM PROBLEMS 68. Do you feel lightheaded or dizzy? 69. Often feel like vomiting or nauseated? F. POSTURE PROBLEMS 70. Do you have backaches? 71. Do you have an abnormal curvature of the spine? 72. Are your legs of unequal lengths? 73. Do you have problems sitting still for prolonged time? 74. Do you cradle the phone between your head and shoulders? 75. Does your work involve typing/ word processing? 76. Do you wear high heels Seldom Occasionally Frequently G. LIFESTYLE PROBLEMS 77. Are you under a lot of stress? 78. Do you bite your nails, tongue, or lips? 79. Take any mood affecting drugs or stimulants? 80. Do you exercise regularly? 81. Do you usually eat breakfast? 82. Do you work more than 40 hours a week? 83. Do you overeat? H. JAW (TMJ) SYMPTOMS 84. Have you ever been treated for jaw joint problems, or facial muscle spasms? 85. Do you have difficulty in chewing your food? 86. Do you grind your teeth during the night? 87. Has anyone told you that you grind your teeth? 88. Are you aware of clenching your teeth during the day? 89. Are you aware of clenching your teeth during the night? 90. Are there times when you can t open your mouth widely? 91. Do you have difficulty in opening your mouth widely? 92. Does it hurt to open your mouth widely? 93. Does your mouth go to one side when fully opened? 94. Has your jaw ever locked or were you unable to open or close you mouth? 95. Have you had pain in your jaw joint? 96. Do you hear sounds in your jaw joint? 97. Do you hear grating sounds in your jaw joint? 98. Do you hear or feel a clicking or popping in your jaw joint? 99. Does your jaw make clicking or popping sounds when you chew? 100. Does your jaw feel tired after a big meal? 101. Have you experienced numbness of shoulders, arms, hands, or fingers? 102. Do you have pain in your neck and/or shoulders? I. TRAUMA RELATED PROBLEMS 103. Accident or trauma to face? 104. Accident or trauma to jaw? 105. Accident or trauma to head? 106. Have you ever received a severe blow to the side of the head or jaw? 107. Accident or trauma to neck? 108. Whiplash or neck injury? 109. Have you worn a cervical traction neck collar? 110. Has there been a strain or stretching of the jaw while yawning, chewing, or opening the mouth wide? 111. Have you experienced a fall within the last two years? TMJ 3 of 4
5 J. Are there any other significant medical or dental problems? (Please Explain) III. PRACTITIONERS Please indicate which practitioners you have seen since your pain began for treatment and relief of pain. Have w 1. Acupuncturists 2. Allergist 3. Anesthesiologist 4. Asian Medicine 5. Cardiologist (heart) 6. Chiropractor 7. Spiritual Counselor 8. Dentist 9. Dermatologist (skin) 10. Dietician 11. E.N.T. 12. Endocrinologist 13. Faith Healer 14. Family Physician 15. Gynecologist/Obstetrician 16. Hypnotist 17. Internist 18. Massage Therapist 19. Naturopath 20. Neurologist 21. Neurosurgeon 22. Nutritionist 23. Ophthalmologist (eyes) 24. Optometrist 25. Orthopedist (bones, joints) 26. Orthodontist 27. Osteopathic physician 28. Pediatrician (children) 29. Physical therapist 30. Physiatrist 31. Plastic Surgeon 32. Proctologist 33. Psychiatrist 34. Psychologist 35. Radiologist 36. Rheumatologist 37. Surgeon 38. Other Other 2 Seen Have Seen Seeing w Seeing IV. PAIN SUMMARY Please identify your areas of pain indicating right R and/or left L that you presently or frequently experience. 1. Top of head R L 2. Back of head R L 3. Frontal headache R L 4. Eye and eyebrow R L 5. Temporal headache R L 6. Jaw and cheek R L 7. Ear and jaw joint area R L 8. Toothache R L 9. Front of neck and throat R L 10. Side of neck R L 11. Back of neck R L 12. Upper thoracic of back R L 13. Mid-thoracic of back R L 14. Lower back R L 15. Back of shoulder R L 16. Front of shoulder R L 17. Back of arm R L 18. Front of arm R L 19. Upper chest area R L COMMENTS: To the best of my knowledge, all the preceding answers are true and correct. If deemed advisable, I grant permission for my physician to be contacted for information and advice. If I have any change in my health or medications that is not reported above, I will inform the doctor at my next visit. Patient/Responsible Party Signature Date TMJ 4 of 4
6 Name Date Draw painful areas in solid red and sensitive areas in multiple red dots. Draw painful areas in solid red and sensitive areas in multiple red dots.
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Jennifer Unger Waters, D.D.S., P.C Washington Avenue Golden, CO (303)
Jennifer Unger Waters, D.D.S., P.C. 1607 Washington Avenue Golden, CO 80401 (303)279-6621 WELCOME We are pleased to welcome you to our practice. Please take a few minutes to fill out this form as completely
Patient Intake Dr. Kimberly Bensen For TMJ Symptoms
PATIENT NAME: DATE: EMAIL ADDRESS: @ ADDRESS: CITY: STATE: ZIP: Primary PHONE: SOCIAL SECURITY #: AGE: DOB / / SEX: M F HEIGHT: WEIGHT: On the diagram below, place a number (none 0 to 10 worse), that corresponds
PATIENT INFORMATION SCHOOL/LOCATION
PATIENT INFORMATION WWW.FAMILYCAREDENTISTRY.NET Date: NEW PATIENT UPDATE Patient: LAST FIRST MI PREFERRED TITLE MALE FEMALE CHILD* STUDENT** SINGLE MARRIED DIVORCED WIDOWED *IF CHILD, PROVIDE PARENT/GUARDIAN
CONSULTATION ADMITTANCE FORM
CONSULTATION ADMITTANCE FORM Last Name: First Name: Address: City Postal Code: Home Phone: Work Phone: Age: Birth date (dd/mm/yr): Sex: M / F Height Weight Occupation: Alberta Health Care #: PLEASE CHECK
Caspian Acupuncture -- Health History Form Anita Tayyebi EAMP, LAc. 652 SW 150 th St Burien WA 98166
Frist Name Last: Date Phone (H) (C) (W) E-mail Address City State Zip Age DOB Place of Birth _ Marital/Partnership Status Preferred Gender Pronoun _ Profession Family Physician Telephone # Referred By
WELCOME Patient Registration Date:
Patient Information WELCOME Patient Registration Date: Mr. Mrs. Ms. Dr. Name: Last First MI Address: Street Apt. # City State Zip Code Home Tel #: Work #: Cell #: Sex: Female Male Birth Date: Married Single
Sound View Acupuncture and Chinese Herbs 5410 California Ave SW, #202, Seattle, WA
Sound View Acupuncture and Chinese Herbs 5410 California Ave SW, #202, Seattle, WA 98136 206.200.3595 Today s date Name Legal name (if different) Phone (primary) (secondary) Address City State Zip Email
PATIENT INFORMATION DENTAL HEALTH HISTORY
PATIENT INFORMATION Welcome to Pristine Family and Implant Dentistry. We appreciate the confidence you place with us to provide dental services. To assist us in serving you, please complete the following
SLEEP SCREENING QUESTIONNAIRE
SLEEP SCREENING QUESTIONNAIRE This questionnaire was designed to provide important facts regarding the history of your sleep condition. To assist in determining the source of any problem, please take your
PREVIOUS ADDRESS: EMPLOYED BY: ADDRESS: SS#: HOME PHONE: WORK PHONE:
SLEEP SCREEIG QUESTIOAIRE This questionnaire was designed to provide important facts regarding the history of your sleep condition. To assist in determining the source of any problem, please take your
PERSONAL INFORMATION REASONS FOR SEEKING CHIROPRACTIC CARE
Patient# WELCOME Today s Date / / Please fill out this form as completely as possible. Please print. PERSONAL INFORMATION Name What you prefer to be called Age Date of Birth / / Sex SS# E-Mail Home Address
OhioHealth Orthopedic & Sports Medicine Physicians
Page 1 of 6 OhioHealth Orthopedic & Sports Medicine Physicians 335 Glessner Avenue, Mansfield, Ohio 44903 PATIENT INTAKE ASSESSMENT OFFICE USE ONLY Fax to: OR Control 419-520-2831 For Joint Replacement
PATIENT MEDICAL HISTORY
Patients Name: PATIENT MEDICAL HISTORY Address: Date of Last Visit: Date of Med History City: State: Zip: Email: Home Phone: Work Phone: Birth Date: Social Security No: Marital Status: Primary Dental Guarantor:
Patient: Date: Please describe your tooth sensitivity pain to a 5 second ice water swish:
DTR/FDH Scaling Form Patient: Date: A) Tooth Sensitivity Pain Scale Office Use: Rate your tooth sensitivity pain on a scale from 0 to 10: With EMG W/O EMG 0 no pain whatsoever preop postop 1 I almost never
Charleston Hematology Oncology Associates, PA Medical History
Charleston Hematology Oncology Associates, PA edical History Patient Name: amily History Date of Birth (Please write in names) If Living: If Deceased: Age Health Age at Death Cause of Death ather other
N N X X === === === === N N X X === u u s s. Physician Signature: OrthoNeuro
Physician Signature: OrthoNeuro Date: Name: Date: Age: SS#: Sex: DOB: Referring Physician: Referring Physician Address: Mark the areas on the corresponding figures where you feel the described sensations.
CONSULTATION ADMITTANCE FORM
CONSULTATION ADMITTANCE FORM Last Name: _ First Name: Sex: M / F Address: City Postal Code: Home Phone: Work Phone: Cell Phone: Cell Phone Provider: E-mail: Occupation: Marital Status: No. of children:
New Patient Medical History and Intake Form Medical Marijuana ( MMJ ) Certification
Name Social Security Number Address: Street: _ New Patient Medical History and Intake Form Medical Marijuana ( MMJ ) Certification Date of Birth Gender: Male Female City: State Zip Code E-mail: Home Phone:
Emotional Relationships Social Life Sexually Recreation
Name Date Address City State Zip Married Single Partner Divorced Widowed Date of Birth SS# Email Work Phone Home Phone Cell Phone Occupation Referred by Emergency Contact Family Physician Contact May we
55 S. Main Street, Driggs, ID (208)
Elements of Health 55 S. Main Street, Driggs, ID 83422 (208) 920-0312 Name: (first) (middle) (last) Date: / / Address: Phone: / street address city zipcode home / cell Date of Birth: / / Age: Gender: M/F
Medical History Questionnaire
Medical History Questionnaire OFFICE USE Patient ID: FORM DATE: / / NAME: DATE OF BIRTH: / / Allergens No known allergens Iodine Plastic Antibiotics Latex Sedatives Aspirin Local anesthetics Sleeping pills
WELCOME TO THE MILLER CHIROPRACTIC CLINIC
WELCOME TO THE MILLER CHIROPRACTIC CLINIC We are pleased that you have chosen to consult us regarding your health. In order to help us evaluate your condition thoroughly, please complete the following
Address, including apt # City State Zip. Do you have an address? We do not share addresses with anyone. Home: ( ) Work: ( ) Cell: ( )
GETTING TO KNOW YOU Welcome to transcendentist and the office of Dr. Fred Pockrass! We are committed to your total wellbeing and to helping you take the best care of your mouth. We know this is an extensive