TMD/Pain Patient Questionnaire

Pain History

Pain Qualities

Which side are the headaches worse?

Headache spreads to?

---SEVERITY ON A SCALE OF 0-10---

---0= No Pain 10= Worst Pain Imaginable---

---Duration---

duration option

---Experience in Pain---

duration option

12 + 12 =

History of Accident

Complete this section if you were involved in an accident, illness, or traumatic incident related to the current visit.

Cause of Pain or Condition

Select one:

History of Accidents

Select one

Select one

New Field If you were in a vehicle where was it hit?

Trauma

Did your...

Forcibly strike...

2 + 8 =

Treatment History

List any treatments you have had for this problem and all health professionals that you are currently seeing.

1 + 2 =

Other Therapy Attempts

include

7 + 4 =

Epworth Sleep Questionaire

How likely are you to dose off or fall asleep in the following situations?

Sitting and reading

Watching TV

Sitting inactive in 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 a traffic

3 + 3 =

Expanded Medical History

If you have any hearth problem, what kind(s)?

Have you been told you have a heart murmur? If you have any hearth problem, what kind(s)?

Do you have a current medical problem? If you have any hearth problem, what kind(s)?

If you have any hearth problem, what kind(s)?

Do you have any pain in your chest or shortness of breath?

Do your ankles well?

Has your physician ever told you that you are anemic?

Do you have difficulty swallowing?

Do you have a feeling of something stuck in your throat?

Do you ever have any pain or pressure behind your eyes?

Have you ever had or been advised to have neck surgery?

Do your ears feel itchy, stuffy, or congested?

Do you have difficulty with pain in your ears when changing altitude?

Are you depressed?

Have you noticed any changes in your hearing?

Do you have emotional anxiety/ nervousness problems?

6 + 3 =

DENTAL HISTORY

Have you been told that you have periodontal (gum) disease?

Do you bite your nails?

Have you ever had oral surgery?

Do you wear dentures or partial dentures?

TMJ HISTORY

If so, are they comfortable?

Do you ever have a burning or painful sensation in your mouth?

Do you get a popping, clicking, or grinding noises when you open or close?

Do you ever awaken with an awareness of your teeth or jaws?

Have you ever been told you grind your teeth during sleep?

Do you have trouble opening your mouth widely?

Do you feel your bite is different, unstable or comfortable?

If you have sought treatment for a TMJ problem, did it help?

Do you or have you had any pain in the following areas?

Do your problem affect your ability to chew?

Do your joint noises affect other others while eating?

7 + 9 =

Signature

Sign this questionnaire using your mouse or finger on touch devices.

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9 + 9 =