TMD Pain Questionnaire Page 2 of 3

Medical History

Acid Reflux

Anemia

Atherosclerosis

Arthritis

Asthma

Atrial Fibrillation

Autoimmune disorder

Bleeding easily

Blood pressure- High

Blood pressure- Low

Bruising easily

Cancer

Chemotherapy

Chronic fatigue

Chronic pain

COPD

Coronary heart disease

Current pregnancy

Depression

Diabetes

Difficulty sleeping

Dizziness

Emphysema

Glaucoma

Gout

Heart attack

Heart murmur

Heart pacemaker

Heart valve replacement

Hemophilia

Hepatitis

Hypertension

Hypoglycemia

Immune system disorder

Insomnia

Ischemic heart disease (reduced blood supply)

Kidney problems

Liver disease

Meniere's disease

Mitral valve prolapse

Mood disorder

Multiple Sclerosis

Muscular Dystrophy

Nasal allergies

Neuralgia

Osteoarthritis

Osteoporosis

Parkinson's disease

Prior orthodontic treatment

Radiation treatment

Rheumatic fever

Sinus problems

Rheumatoid arthritis

Sleep apnea

Stroke

Thyroid disorder

Tuberculosis

Tendency for ear infections

Tumors

Urinary disorders

Other concerns not included in the options

Surgical Operations

Other concerns not included in the options

Family History Has any member of your family had

Other concerns not included in the options

Social History

Tobacco Use

Cigarettes

Other Tobacco

Date of quit

Alcohol Use

New Field Do you drink alcohol

Caffeine Intake

New Field

Symptoms

HEAD PAIN

Front of your head (Frontal)

Top of the head

Back of your head

In your temples

JAW PAIN

Jaw pain - on opening

Jaw pain - while chewing

Jaw pain - at rest

JAW SYMPTOMS

New Field

Jaw clicking

New Field

MOUTH AND NOSE RELATED CONDITION

EAR RELATED CONDITIONS

EYE RELATED CONDITIONS

THROAT, NECK & BACK RELATED CONDITIONS CONTINUED

History of Symptoms