Orofacial pain and temporomandibular joint disorder patient history and questionnaire. Name: Sex: M F Date of Birth: / / Age:

Similar documents
Facial Problem(s) Questionnaire

Please do not write in this space.

Orofacial Pain Examination Form

RESEARCH DIAGNOSTIC CRITERIA FOR TEMPOROMANDIBULAR DISORDERS: REVIEW, CRITERIA, EXAMINATIONS AND SPECIFICATIONS, CRITIQUE

New Patient Evaluation Form

Kingsland Family Dental Registration and Medical History

A B O U T Y O U D E N T A L I N F O R M A T I O N

Married Single Widowed Legally Separated. Full Time Part-time Retired Not Employed Currently

Emad F. Abdallah, DMD, MS Member, American Association of Orthodontists Diplomate, American Board of Orofacial Pain

Facial Problem Questionnaire

Please fill out the following form in as much detail as possible. Please Print. Name. Address. City State Zip. Home Phone Office Phone.

* CC* PATIENT QUESTIONNAIRE

NEW Adult Patient Information

Last Name: First Name: Address: City: State: Zip: Home #: Work #: Mobile #: Gender: SS#: DOB: Marital Status: Employer:

MEDICAL QUESTIONNAIRE (male)

3. Have you had any serious illness, operation, or been hospitalized in the past five years? Venereal disease (STD s), Sickle cell disease medication

REGISTRATION AND HEALTH HISTORY

Comprehensive History, Consult, and Evaluation Form

KODISH DENTAL GROUP. If you could whiten your teeth for a cost anyone could afford, would you do it? Y N

MEDICAL QUESTIONNAIRE (female)

PATIENT INFORMATION. Date: Patient Name: SS#: Address: City: State: Zip: Phone: (Home) (Work) (Cell)

Welcome to the office of

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

CASE HISTORY. Address: City: State: Zip: Date of Birth: Age: address: Occupation: Employer: Spouse's Employer: Referred by:

Medical History Questionnaire

PLEASE INDICATE ANY OF THE FOLLOWING YOU ARE NOW EXPERIENCING:

Eastman Dental Hospital. Temporomandibular disorder. Facial Pain Team

Temporomandibular Joint Disorders

Sound View Acupuncture and Chinese Herbs 5410 California Ave SW, #202, Seattle, WA

PATIENT INFORMATION. Address: Street City State Zip Home phone: Work phone: Cell phone: address: Patient s or parent s employer: Occupation:

CHIROPRACTIC INTAKE FORM

Where is the Temporo-Mandibular Joint?

Chiropractic Applied Kinesiology Vitamins Herbs Homeopathy Health Education Classes PATIENT REGISTRATION

*521634* Sleep History Questionnaire. Name of primary care doctor:

New Patient Medical History Intake Form

ABOUT YOU (Please print clearly) Name Birth Date Age Sex: Male Female Referring MD Mailing Address: Address

Amarillo Surgical Group Doctor: Date:

PHYSICAL THERAPY HEALTH QUESTOINNAIRE

MEDICAL HISTORY FULL NAME D.O.B. SEX

Patient Intake Form for Acupuncture Treatment at Infinite Healing

John Wayne Cancer Institute Dr. Foshag Dr. Faries Dr. Bilchik Dr. Leuchter

Orthodontic Questionnaire. Please tell us why you have presented for evaluation and possible treatment. Dental History

Emotional Relationships Social Life Sexually Recreation

Patient Health Questionnaire

Dr. Brett A. Morgan PATIENT INFORMATION TRUE HEALTH Chiropractic Physician Applied Kinesiologist So. Charleston, WV PERSONAL INFORMATION

MEDICAL HISTORY RECORD

TMJ QUESTIONNAIRE. TMJ 1 of 4. Name: Date: Primary Care Physician Name and Phone #: Primary Care Physician

Patient History (Please Print)

Registration. Secondary Dental Insurance Subscriber s Name Date of Birth Social Security # Relationship to Patient Subscriber s Employer

Address: City: Postal Code: Emergency Contact: Phone# Relationship: Who may we thank for referring you to this office?

Name: Date: Sex: Male Female Date of Birth(DD/MM/YY): Address: City: Postal Code: Phone #: (Home) (Work) (Cell) (Other) Address:

We Would Like to Get to Know You Better!

BROADWAY SPORTS & INTERNAL MEDICINE, P.S TH AVE NE SUITE 202 BELLEVUE, WA P: F:

NEW PATIENT HEALTH HISTORY

New Patient Questionnaire. Today s Date: Date of Birth: Name: Home Address: City: State: Zip: Home Phone: Work Phone: address: Referred by:

New Patient Paperwork

Island Acupuncture. Patient General Information. Last Name First Name. Home Phone Cell Phone. Work Phone . Date of Birth Occupation

Welcome to the Koala Center for Sleep Disorders

COMPREHENSIVE HEALTH & WELLNESS PROFILE

Patient Name: Physician s Name Phone # Date of last physical Place a mark on yes or no to AIDS/HIV. Yes No Liver Disease.

ILLINOIS BONE AND JOINT INSTITUTE Rheumatology Medical History Form

Last: First: MI: Nickname:

Julia A. Hallisy, D.D.S., Inc.

NEW PATIENT QUESTIONNAIRE For Dr Benoy Benny. Section 1: Today s Date: Date of Birth: Age:

DATE OF FIRST INJURY OR ILLNESS NAME DATE OF BIRTH ADDRESS M F AGE MARITAL STATUS CITY STATE ZIP CODE HOME PHONE NUMBER ( ) WORK PHONE NUMBER ( )

New Patient Specialty Intake Form Department of Surgery

Capital Health Medical Center - Hopewell NEUROSURGICAL-ONCOLOGY Patient History

Twohig Dentistry Dental and Oral Health Information

RHEUMATOLOGY PATIENT HISTORY FORM

N N X X === === === === N N X X === u u s s. Physician Signature: OrthoNeuro

HISTORY OF PRESENT ILLNESS A. TELL US ABOUT YOUR PAIN PROBLEM

Inner Balance Acupuncture

HEALTH INFORMATION FORM

Cancellation & No-Show Appointment Policy

FACIAL PAIN DYSFUNCTION EVALUATION. Name Birthdate / / Age. Home # ( ) Cell # ( ) Work # ( ) Address Apt. # City State Zip.

PATIENT NAME DATE CONSULTATION QUESTIONNAIRE

Patient Registration. Additional Information. Insurance Information. Patient s Full Name: Date: Home Address:

Caspian Acupuncture -- Health History Form Anita Tayyebi EAMP, LAc. 652 SW 150 th St Burien WA 98166

The Craniofacial Pain, Headache and Sleep Center Health History Part II

New Patient Information

Health History & Neurotoxic Questionnaire

Extended Health Care Company Do you need any help retaining information about your health insurance coverage? Yes No

Patient Intake Dr. Kimberly Bensen For TMJ Symptoms

Chiropractic Case History/Patient Information

WELCOME TO THE NORTHSHORE UNIVERSITY HEALTHSYSTEM SLEEP CENTERS

Chiropractic Case History/Patient Information

Bridges Family Wellness PC. New Patient Intake. Bridges Family Wellness Intake Form SE Lake Rd, Suite 102 Milwaukie, OR

CHIROPRACTIC ASSOCIATES CLINIC

PATIENT INFORMATION HEALTH INFORMATION

CHIROPRACTIC PLUS Phone: (616) Dr. Daniel Ohlman Fax: (616) Applied Kinesiology

New Patient Medical History and Intake Form Medical Marijuana ( MMJ ) Certification

NEW PATIENT INFORMATION FORM

Eastern Body Therapy

Chiropractic Case History/Patient Information. Social Security # Home Phone: Address: City: State: Zip: address: Fax # Cell Phone:

Cascadia Chiropractic Centre

Questionnaire for Lipedema Patients

Chiropractic & Progressive Rehab HISTORY OF ILLNESS / INJURY / PAIN

CONQUER YOUR JAW PAIN

PATIENT HEALTH HISTORY

HEALTH INFORMATION FORM

Transcription:

Orofacial pain and temporomandibular joint disorder patient history and questionnaire Date: / / Name: Sex: M F Date of Birth: / / Age: Occupation: Physician: Dentist: Referred by: Chief Complaint/Concern: Location Please draw where your pain occurs. If you have multiple sites of pain, please number them from one to ten with the most painful site being #1. Has the location or type of pain changed since its initial occurrence? No Yes Explain:

GENERAL PAIN / PROBLEM ASSESSMENT 2 Do you have? Facial Pain No Yes, Rt. Yes, Lt. Past Dental pain No Yes, Rt. Yes, Lt. Past Jaw Joint Pain No Yes, Rt. Yes, Lt. Past Jaw muscle pain No Yes, Rt. Yes, Lt. Past Headaches No Yes, Rt. Yes, Lt. Past Neck Pain No Yes, Rt. Yes, Lt. Past Shoulder Pain No Yes, Rt. Yes, Lt. Past Earaches No Yes, Rt. Yes, Lt. Past Ringing in the ears No Yes, Rt. Yes, Lt. Past Dizziness No Yes, Rt. Yes Past Change in hearing No Yes, Rt. Yes, Lt. Past Change in bite No Yes, Rt. Yes, Past HEAD and NECK PAIN / SYMPTOMS 1. Date of Onset and side: (R) (L) 2. Area(s) of onset: 3. Circumstances surrounding onset, if known: 4. Pain Type: Superficial Piercing Throbbing Pulsing Severe Spontaneous Fit-like 5. Pain Quality: Burning Aching Bright Dull Itching 6. Pain Intensity: Mild Moderate Severe Incapacitating Limits activities: 7. Numbness: Face Head Neck/Shoulder Arm/Hand Other: 8. Pain Frequency: Constant ( ) Times/Day ( ) Times/Week ( ) Times/Month 9. Pain Duration: Momentary Seconds to Minutes Hours All Day Days Constant 10. Pain Localization: Localized to Diffuse over Radiates to 11. Time of greatest intensity: On Awakening Morning Afternoon Evening Night 12. Current Pain: Increased Decreased Unchanged When? 13. Onset: Abrupt Gradual Disappearance: Abrupt Gradual 14. Can the pain awake you out of sleep? Yes No 15. Pain is triggered by sensitivity to: Food Light Sound Odors Touch Other: 16. Pain aggravated by: Face movement Jaw movement Tongue movement Chewing Talking Swallowing Head position Body position Activity Tension Fatigue Heat/Sun Driving Foods Clenching/Grinding Other: 17. Pain accompanied by: Nausea Eye spots Dizziness Sweating Neck stiffness Stomach cramps 18. Pain is relieved by: 19. Longest pain-free period? 20. Pain in specific teeth? 21. Sore throat or difficulty swallowing? Yes No

EAR / TMJ / DENTAL SYMPTOMS 3 1. Do you have pain in or about the ear(s)? No Yes, right Yes, left 2. Do you have dizziness? Spinning Lightheaded Fainting Meniere s disease 3. Do you have ear noise? Ringing: R L Popping: R L Whooshing: R L Clicking: R L 4. Have you noticed a decrease in hearing acuity? No Yes Stuffiness Excessive ear wax R L 5. Do you have a history of ear infections or operations? No Yes, right Yes, left 6. Do you have pains in your Tongue Throat Right cheek Left cheek 7. Does your jaw hurt? No Right Left 8. Do you have jaw or facial muscle fatigue? No Yes, when: 9. Have you noticed any facial swelling? No Yes, Right Yes, Left 10. Does your jaw make a noise? Right side No Clicking Popping Grinding Other When? How long? Left side No Clicking Popping Grinding Other When? How long? 11. Has your jaw ever locked? Right side No Yes Current In the past Open When? How frequent? Closed When? How frequent? Left side No Yes Current In the past Open When? How frequent? Closed When? How frequent? 12. Do you grind or clench your teeth? No Yes Daytime Night 13. Do you have sore or sensitive teeth? No Yes Hot Cold Sweets Chewing 14. Do you lose or break filings? No Yes Do you have cracked or broken teeth? No Yes 15. Do you have loose or mobile teeth? No Yes Do your gums bleed? No Yes 16. Do your gums feel tender or swollen? No Yes Have you ever had periodontal treatment? No Yes When? Dr. 17. Do you have noticeable wear on your teeth? No Yes Food traps? No Yes 18. Are you missing any teeth? No Yes Have they been replaced? No Yes if so, how? Fixed bridge Removable partial Full denture Dental implant 19. Are you comfortable with the replacement? Yes No Comment? 20. Have you noticed a change in your bite? No Yes When?

GENERAL WELLNESS ASSESSMENT 4 Marital status: Single Married Separated Widowed Remarried Do you have difficulty getting to sleep? No Yes Do you sleep well? Yes No Sometimes Is your sleep interrupted? No Yes Do you consider yourself to be under a lot of stress? No Yes Distress or Mental anguish caused by: Spouse Children Mother Father Friends Work Economics Other: How would you rate your irritability level? Mild Moderate Severe How would you rate your anxiety level? Low Moderate High How is it experienced? Ave you had a problem with? None Concentrating Memory Panic attacks Crying spells Weight loss/gain Libido Anger outbursts Impulsiveness Appetite Have you had a problem with? None Nervous Stomach Ulcers Skin disease Allergies Occupation: Hours worked/week: Years employed at present job: Do you like your job? Yes No Explain: Is there anything about your job that causes you excessive stress or anxiety? What job would you like to do? Have you had a change in employment? No Yes Do you exercise? Daily ( ) x s per week Rarely Never What do you do for exercise? Do you have or have you ever had arthritis? No Yes Past Where? Does your family have a history of arthritis? No Yes Past Where? Does your pain keep you from doing anything? No Yes What? Do you recall any injury to your jaw, head or neck? No Yes Date(s): Describe: Do you take any medications for pain? No Yes If yes, what? Do you take any medications for relaxation or sleep? No Yes If yes, what? Have you had any treatments for your problem? No Yes If yes, what? Bite splint Medication Physical Therapy Chiropractic Counseling Occlusal adjustment Orthodontics Surgery Medication Other

5 Please add anything else that you feel is important: Signature: Date:

2024 © healthdocbox.com Privacy Policy | Terms of Service | Feedback