The Craniofacial Pain, Headache and Sleep Center Health History Part II
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- Ira Norman
- 6 years ago
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1 Patient s Date: Age: Sex: Date of Birth: Home Occupation: Chief Complaint: Duration of the problem: Problem m ost severe: Morning Afternoon Evening Sleeping Eating No pattern SYMPTOMS Left Righ t Face Pain Forehead Cheek Nose Around Eyes Head Pain Front Back Side Top Ear Pain Stuffy Ringing Loss of hearing Eye Pain Redness Pressure Loss of Focus Arm/Fingers Pain Tingling Nu mbness Weakness Throat Pain Tightness Dryness Difficult to swallow Jaw Joint Pain Clicking Grinding Locking open/closed Upper Back Pain Stiffness Spasm Noise on movement Lower Back Pain Stiffness Spasm Noise on movement Dental Problem: Bite Problem: Other: Pain Type: Sharp Stabbing Burning Throbbing Dull Deep Prickling Mild Mild-Moderate Moderate Moderate-Severe Severe Agony Location: Localized Generalized Radiating Migrating Duration: Intermittent Recurrent Continuous What is your worst symptom? What Makes it feel better? What Makes it Feel Worse? Family History of TMJ disorders and Pain: Habit History: Gum Chewing Nail Biting Musical Instrument Other: Clenching Grinding Daily A ct ivit ies Type of Exerc ise: Home/Work Daily Habits: Usual Posture and position at work: Frequency: -1-
2 The Craniofacial Pain, Headache and Sleep Center Health Hist o ry Part II Please indicate pain areas, type and level of pain / discomfort on the diagram be low as felt on your worst day. Type of Pain: B: Burning T: Throbbing S: Sharp D: Dull No Pain Mild P ain Moderate P ain Severe P ain Agony U n beara b le One Kneeland St reet, 6 th floor, Boston, MA T: F: Web: -2-
3 history -3-
4 -4-
5 Doctor Information Who referred you to this office? Please list previous and present health care providers. -5-
6 Trauma History: In an effort to provide you with the best care possible, it is very important that we have as complete and as detailed a history of injuries you have sustained and treatments received. In addition there are certain lifestyle factors which interfere with treatment. Therefore we will be interested in aspects of your life which you may, at first glance, this unrelated to the problems which pro mpted your coming to the Gelb Center. Have you been involved in accidents in the past which you head was snapped as in whiplash auto accidents?. If so please list every accident of this type. Have you received a blow to the face or ja w? type.. If so please list every accident or incident of this Have you been involved in any other types of accident, fall, injury requiring sur g er y? If so please list every incident. Please list the treatment you have received for accidents or incidents listed. -6-
7 Please list previous treatments for the condition which prompted your coming to this center. Are you presently in lit igation re lated to head, neck, back and/or symptoms Yes No If yes, please have copies of any medical records related to this injury forwarded to our center. Nature of lit igation: Are you currently not working due to disability? Yes No Partial disa bility T ot al dis ability If yes, what is the nature of your disability? Date you stopped working When has your physicians indicated that you can t return to work? -7-
8 CHR O N OLOGI C A L HISTO R Y Please give a detailed ch ron ologi cal history of the condition fo r which you have come to be examin ed. It is pertinent to your treatment that this portion is filled out with specific info rmation as to the onset of your illness to present t ime. FOR PATIENT S US E DOCTOR S US E (Add additional pages if needed) -8-
Emad F. Abdallah, DMD, MS Member, American Association of Orthodontists Diplomate, American Board of Orofacial Pain
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