HEAD, NECK AND FACIAL PAIN QUESTIONNAIRE
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- Godwin Oliver
- 6 years ago
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1 HEAD, ECK AD FACIAL PAI QUESTIOAIRE Form 401A This questionnaire was designed to provide important facts regarding the history of your pain or condition. The information you provide will assist in reaching a diagnosis. Please take your time and answer each question as completely and honestly as possible. Please sign each page. PATIET IFORMATIO MR. MS. MISS MRS. DR. AME: TODA'S DATE First Middle Initial Last AGE: BIRTH DATE: MALE FEMALE ADDRESS: EMPLOED B: ADDRESS: CIT/STATE/ZIP: SS#: HOME PHOE: WORK PHOE: RESPOSIBLE PART: FAMIL PHSICIA: REFERRED B: ADDRESS: umber #1 = the most severe symptom Back Pain Dizziness Ear Congestion Ear Pain Frequency Intensity Facial Pain Fatigue Headaches Frequency: (1- SELDOM, 2-OCCASIOAL, 3- FREQUET, 4- EVER DA) Intensity: (0 is O PAI and 10 is MOST SEVERE PAI) Jaw Clicking Jaw Joint oises Jaw Locking Jaw Pain Limited Mouth Opening Muscle Twitching eck Pain Pain when Chewing Ringing in the Ears Shoulder Pain Sinus Congestion Throat Pain Visual Disturbances Other - write in:
2 Form 401A - Page 2 LIST A MEDICATIOS/SUBSTACES WHICH HAVE CAUSED A ALLERGIC REACTIO: Antibiotics Aspirin Barbiturates Codeine Iodine Latex Local anesthetics Metals Penicillin Plastic Sedatives Sleeping pills Sulfa drugs Other LIST A MEDICATIOS CURRETL BEIG TAKE: Antibiotics Anticoagulants Barbiturates Blood thinners Codeine Cortisone Diet pills Heart medication Insulin Muscle relaxants erve pills Pain medication Sleeping pills Sulfa drugs Tranquilizers Other PLEASE LIST A TREATMETS OU HAVE HAD FOR THIS PROBLEM AD ALL HEALTH PROFESSIOALS THAT OU ARE CURRETL SEEIG: Practitioner Specialty Treatment & approximate date MEDICAL HISTOR (Please indicate dates on questions checked ES) Adenoids Removed Tonsils Removed Anemia Arteriosclerosis Asthma Autoimmune disorders Bleeding easily Blood pressure High Low Bruising easily Cancer Chemotherapy Chronic fatigue Cold hands & feet Current pregnancy Depression Diabetes Difficulty concentrating Dizziness Emphysema Epilepsy Excessive thirst Fibromyalgia Fluid retention Frequent cough Frequent illnesses Frequent stressful situations General anesthesia Glaucoma Gout Hay fever Hearing impairment Heart murmur Heart disorder Heart pacemaker Heart palpitations Heart valve replacement Hemophilia Hepatitis Hypoglycemia Patient Signature Date 2009 TMJ PRACTICE MAAGEMET ASSOCIATES, IC. REPRIT RIGHTS OL THROUGH LICESIG.
3 MEDICAL HISTOR COTIUED Other Immune system disorder Injury to Face eck Mouth Teeth Insomnia Intestinal disorders Jaw joint surgery Kidney problems Liver disease Meniere's disease Menstrual cramps Multiple sclerosis Muscle aches Muscle shaking (tremors) Muscle spasms or cramps Muscular dystrophy eeding extra pillows to help breathing at night ervous system irritability ervousness euralgia Osteoarthritis Osteoporosis Ovarian cysts Parkinson's disease Poor circulation Prior orthodontic treatment Psychiatric care Radiation treatment Rheumatic fever Rheumatoid arthritis Scarlet fever Form 401A - Page 3 Shortness of breath Sinus problems Skin disorder Slow healing sores Speech difficulties Stroke Swollen, stiff or painful joints Tendency for: Frequent Colds Ear Infections Sore Throats Tired muscles Tuberculosis Tumors Urinary disorders Wisdom teeth (Third Molar) extraction SMPTOMS: PLEASE IDICATE LOCATIO AD TPE OF A HEAD PAI L= Left R=Right B=Both sides HEAD PAI L R B L R B L R B L R B L R B LOCATIO Front of your head (Frontal) Entire head (Generalized) Top of your head (Parietal) Back of your head (Occipital) In your temples (Temporal) SEVERIT FREQUEC DURATIO MODERATE MILD SEVERE OCCASIOAL (MOTHL FREQUET OR LESS} (WEEKL) COSTAT (EVER DA) SECODS MIUTES HOURS DAS WEEKS JAW PAI L R B L R B L R B JAW SMPTOMS Jaw pain - on opening Jaw pain - while chewing Jaw pain - at rest EE RELATED CODITIOS Jaw clicks Jaw locks closed Jaw locks open Jaw popping Teeth clenching Teeth grinding Blurred vision Double vision Eye pain Pain or pressure behind the eyes Photophobia (extreme sensitivity to light) EAR RELATED CODITIOS Buzzing in the ears Ear congestion Ear pain Hearing loss Pain behind the ear Pain in front of the ear Recurrent ear infections Tinnitus (ringing in the ear) THROAT ECK & BACK RELATED CODITIOS Back pain - lower Back pain - middle Back pain - upper Chronic sore throat Constant feeling of a foreign object in throat Difficulty in swallowing Limited movement of neck eck pain umbness in the hands or fingers Patient Signature Date 2009 TMJ PRACTICE MAAGEMET ASSOCIATES, IC. REPRIT RIGHTS OL THROUGH LICESIG.
4 THROAT ECK & BACK RELATED CODITIOS (Continued) Sciatica Scoliosis Shoulder pain Shoulder stiffness Swelling in the neck Swollen glands Thyroid enlargement Tightness in throat Tingling in the hands or fingers Torticollis MOUTH & OSE RELATED CODITIOS Broken teeth Burning tongue Chronic sinusitis Dry mouth Frequent biting of cheek Frequent snoring Other Form 401A - Page 4 HISTOR OF SMPTOMS When did your condition first occur? What do you believe is the cause of your pain or condition? Pick one: Motor vehicle accident Motorcycle accident Work related incident Playground incident Athletic endeavor Fight Fall Accident Illness Injury Unknown If accident, date Other Is there anything that makes your pain or discomfort worse? Is there anything that makes your pain or discomfort better? What other information is important to your pain or condition? FAMIL HISTOR Have any members of your family (blood kin) had: Headaches Heart disease High blood pressure Diabetes SOCIAL HISTOR Occupation Do you have children? If yes, how many children? What are their ages? Are you currently under unusual stress? Recent change in lifestyle? Do you exercise regularly? Do you chew tobacco? umber of caffeine drinks per day Do you smoke? Alcohol consumption umber of Packs Cigarettes per Day Week one Occasional Social Drinker Daily Patient Signature Date 2009 TMJ PRACTICE MAAGEMET ASSOCIATES, IC. REPRIT RIGHTS OL THROUGH LICESIG.
5 DRAW OUR PAI PATTERS FOLLOWIG THIS KE: EXAMPLE Form 401A - Page 5 Form TMD-Sleep Mild, numbing pain MILD PAI MODERATE PAI SEVERE PAI B Burning D Dull umbing P Pressure S Sharp T Tingling R Radiating Moderate, dull pain Severe, radiating pain Pressure Patient Signature Date 2009 TMJ PRACTICE MAAGEMET ASSOCIATES, IC. REPRIT RIGHTS OL THROUGH LICESIG.
6 THE EPWORTH SLEEPIESS SCALE Howlikelyareyoutodozeofforfallasleepinthefollowingsituations? Checkoneineachrow: Sitting and reading 0 1 o chance of dozing Slight chance of dozing 2 Moderate chance of dozing 3 High chance of dozing Watching TV Sitting inactive in a public place (e.g. a theater or a meeting) As a passenger in a car for an hour without a break Lying down to rest in the afternoon when circumstances permit Sitting and talking to someone Sitting quietly after a lunch without alcohol In a car, while stopped for a few minutes in traffic Total Score: (Add columns 0-3) Patient Signature Date 2006 TMJ PRACTICE MAAGEMET ASSOCIATES, IC REPRIT RIGHTS OL THROUGH LICESIG. Epworth
7 HISTOR OF ACCIDET Form 401A - Page 6 IF OU WERE IVOLVED I A ACCIDET OR A TRAUMATIC ICIDET, COMPLETE THIS SECTIO. DATE OF ACCIDET OR ICIDET (Choose one) WERE OU? A passenger in a vehicle The driver of a vehicle A pedestrian At work IF I A VEHICLE WHERE WAS THE VEHICLE HIT? At front end At rear end At front right area At front left area At rear right area At rear left area AD... (Choose one) Did you fall? Were you hit by an object? Did you hit an object? Other Head on On driver's side On passenger's side Other IDICATE IF THERE WAS A DIRECT TRAUMA. DID OUR Forehead Face Chin Side of head Back of head Top of head Teeth Jaw Other FORCIBL STRIKE Steering wheel Windshield Passenger's side window Driver's side window Passenger's side door Driver's side door Headrest Seat Roof Interior of car Other WERE A AREAS OF OUR BOD PAIFUL SHORTL AFTER THE ACCIDET/ICIDET? Head eck Face Jaw Left shoulder Right shoulder Left arm Right arm Lower back Upper back Other: BRIEFL DESCRIBE THE HISTOR OF SMPTOMS, ACCIDET OR ICIDET: DID OU GO TO THE HOSPITAL? TAKE TO THE HOSPITAL FOR X-RAS & EVALUATIO es o By Car By Ambulance WERE OU SUBSEQUETL RELEASED O (Date) WHICH HOSPITAL? HAS A DOCTOR OR DETIST EVER DIAGOSED A TMJ DISORDER PRIOR TO THE ACCIDET? es o If yes, please explain Patient Signature Date 2009 TMJ PRACTICE MAAGEMET ASSOCIATES, IC. REPRIT RIGHTS OL THROUGH LICESIG.
8 IF OU HAD A PREVIOUS ACCIDET, PLEASE GIVE A ACCURATE DESCRIPTIO, Form 401A - Page 7 ICLUDIG DATE: AMES AD ADDRESSES OF HOSPITALS AD DOCTORS WHERE TREATED FOR THIS PREVIOUS ACCIDET: IF OU HAVE MISSED A WORK PLEASE GIVE DATES: ISURACE IFORMATIO AUTO ISURACE Please mark each insurance category your insurance driver of vehicle's insurance other vehicle's insurance owner of vehicle's insurance Insured Insured's Soc. Sec. o. Relationship Insured's Address City, State, Zip Insurance Co. Insured's Birth date. Adjuster (not agent) Phone o. Insurance Billing Address City, State, Zip Policy o. Claim o. Has this been reported? es o OTHER TPES OF ISURACE HEALTH ISURACE (Complete even if you are covered by auto insurance) Insured Insured's Soc. Sec. o. Relationship Insured's Birth date. Insured's Address City, State, Zip Insurance Co. Adjuster (not agent) Phone o. Insurance Billing Address City, State, Zip Policy o. Group o. I.D. o WORKER'S COMPESATIO Employee Address City, State, Zip Employer Phone o. Supervisor Has this been reported? es o If yes, was treatment authorized? Insurance Co. Insurance Billing Address City, State, Zip Policy o Group o. I.D. o. If you have additional insurance, please enter the information on the reverse side of this form. Patient Signature Date 2009 TMJ PRACTICE MAAGEMET ASSOCIATES, IC. REPRIT RIGHTS OL THROUGH LICESIG.
9 Form 401A - Page 8 ATTORE IFORMATIO If you have an attorney representing you, please complete the following: Attorney's ame Paralegal Phone o. Address City, State, Zip Are you involved in a lawsuit regarding your condition? es o I authorize the release of a full report of examination findings, diagnosis, treatment program, etc., to any referring or treating dentist or physician. I additionally authorize the release of any medical information to insurance companies or for legal documentation to process claims. I understand that I am responsible for all charges for treatment to me regardless of insurance coverage. Patient Signature Date FOR OFFICE USE OL Insurance Company Group Health Auto Government Self Insured Dental Contact Person Effective date of this policy Amount of deductible? TMJ policy exclusions Has it been satisfied? At what percentage are benefits paid? Is there a policy maximum for TMJ disorders? Is precertification required Can benefits be assigned to doctor? es o What information is needed to process the claim? For o Fault: Amount of benefits Mailing Address City, State, Zip Adjuster Assignment approved es o By Other: Patient Signature Date 2009 TMJ PRACTICE MAAGEMET ASSOCIATES, IC. REPRIT RIGHTS OL THROUGH LICESIG.
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Yes No If yes Yes No If yes Yes No If yes Yes No If yes Yes No If yes Yes No If yes. Yes No Yes No
Medical History Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking,
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Sleep Center. Have you had a previous sleep study? Yes No If so, when and where? Name of facility Address
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PATIENT QUESTIONNAIRE Boise Location 7272 W. Potomac Drive Boise, ID (208)
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Jennifer Unger Waters, D.D.S., P.C Washington Avenue Golden, CO (303)
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Huron Medical Sleep Center Saad S. Ahmad, MD
Authorization and Consent for Sleep Testing I authorize the release of any medical information necessary to the durable medical equipment company for therapy, if applicable. I authorize the use of audio
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Sleep Disorders Diagnostic Center 9733 Healthway Drive, Berlin, MD , ext. 5118
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Address City State Zip. Home Phone Cell Work. (For SHPT use only) Emergency Contact Phone
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Initial Patient Health Assessment Form
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Caspian Acupuncture -- Health History Form Anita Tayyebi EAMP, LAc. 652 SW 150 th St Burien WA 98166
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PATIENT REGISTRATION PERSON TO NOTIFY IN CASE OF EMERGENCY. Name: Relationship: Phone:
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Margie Petersen Breast Center
Medical History Questionnaire Name: Sex: Female Male Last First Middle Date of Birth: Age: Birth Place: Mother s Birth Name: Social Security #: - - Marital Status: Single Married/Partnered (how long) Divorced