Date

Patient Name

Last First Middle

Address Telephone (home)

(work)

Age: Date of Birth: Sex : ( ) Male ( ) Female

Marital Status: ( ) Single ( ) Married ( ) Divorced ( ) Widowed

Number of Children Ages

Are you presently employed? ( ) Yes, ( ) Full-time ( ) part-time

( ) No, ( ) unemployed ( ) disabled ( ) retired

Occupation

Who referred you to our clinic?

Address and telephone:

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1. What is the main problem that brings you to this clinic?

2. When did your problem begin?

(Date: moth, year)
3. How did you problem begin?
( ) Jaw Surgery ( ) Blow to jaw/ head / neck
( ) Motor vehicle accident ( ) Dental work
( ) Chewing ( ) Tooth Extraction
( ) Orthodontics (braces) ( ) Stressful Situation
( ) Nothing; pain just came on
Other _ _
4. What is the usual severity of your pain? (Circle the appropriate number)

| |
0 1 2 3 4 5 6 7 8 9 10
No Pain Extreme pain

5. Describe the way your pain typically feels :

( ) Throbbing ( ) Gnawing ( ) Splitting
( ) Shooting ( ) Hot / Buming ( ) Tiring- exhausting
( ) Stabbing ( ) Aching ( ) Sickening
( ) Sharp ( ) Heavy ( ) Fearful
( ) Cramping ( ) Tender ( ) Punishing- Cruel

6. On the diagrams below please outline the areas where you feel pain:

7. How long does the pain typically last?

( ) Less than 1 minute ( ) 6-12 hours
( ) 1-10 minutes ( ) 13-24 hours
( ) Less than 1 hour ( ) several days
( ) 1-5 hours ( ) Constant

8. Which of the following causes or aggravates the pain?

( ) Chewing ( ) Opening mouth wide ( ) Hot or cold foods/ drinks
( ) Talking ( ) Lack of Sleep ( ) Damp or cold weather
( ) Yawning ( ) Playing musical instrument ( ) Stress/emotional upset
( ) Laughing ( ) Riding in a car for long period ( ) Sitting for long period
( ) Singing ( ) eating certain foods ( ) Exercise
( ) Other
9. Which of the following relives the pain?

( ) Exercise ( ) Message of the area ( ) Warm soak/compresses

( ) Heat ( ) Holding jaw in certain position ( ) Ice/cold compresses
( ) Sleep ( ) Moving/manipulating jaw ( ) Pain medication
( ) Other
10. Do you have painful teeth or other painful areas in your mouth?
( ) Yes ( ) No If Yes, please circle the areas on the diagram

11. Check any of the following that you experience?

Numbness in the face or jaw Weakness in jaw muscles

Earache Ringing or buzzing the ears
Ear stuffiness Dizziness
Neck pain Pain in black of head
Back pain Morning stiffness
Easily fatigued Jaw catching
Aches and pains all over body Decreased ability to open your mouth
Numbness/tingling in hands or finger
12. Are you bothered by
headaches? ( ) Yes
( ) No if no, skip to question number 13.
1) On average, how painful are your headaches?
| |
0 1 2 3 4 5 6 7 8 9 10
No Pain Extreme Pain
2) Do you have headaches as often as once per
week? ( ) Yes ( ) No
3) Do you have more than one type of
headache? ( ) Yes ()
No
4) Do you wake up in the morning with a
headache? ( ) Yes ()
No
5) Do you have headaches later in the
day? ( ) Yes ()
No
 6) Do headaches wake you up from
sleep? ( ) Yes
( ) No
7) Is there any nausea or vomiting associated with your
headaches? ( ) Yes ( ) No

8) Is there vision changes associated with your

headaches? ( ) Yes ( ) No

If yes, what kind?

9) What relieves the headache?

( ) Rest ( ) Nothing
( ) Sleep ( ) Exercise
( ) Pain Medications, which ones
13) Have you ever been in an accident or received a “blow” or injury to any part of
your face, head, neck or back?

( ) Yes ( ) No

If yes, when?

Describe the circumstances:

14) Are you aware of your jaw making

sounds? ( ) Yes ( ) No

If yes, place answers the following question, if, no, go to question

#15. Which side? ( ) Right ( ) Left ( ) Both Sides

Describe the nature of the sound:

( ) Clicking ( ) Grating ( ) Popping ( ) Cracking

()
Other

When do you notice the sounds?

( ) Early opening ( ) Moving jaw to the side

( ) Middle opening ( ) Chewing

( ) Wide opening ( ) While closing

Is the sound always present?
( ) Yes ( ) No

Do you feel that the sounds are related to your

pain? ( ) Yes ( ) No

15. Has your jaw over locked open?

( ) Yes ( ) Right side ( ) both sides
( ) No ( ) Left sides

Date of first occurance

If so, can you replace the jaw to normal position

yourself? ( ) Yes ( ) No

16. Has your jaw ever locked closed or partially closed?

( ) Yes ( ) Right side ( ) both sides
( ) No ( ) Left sides

17. How many times has your jaw locked open or closed during the past

year? ( ) None # of times

18. Do you have pain when your jaw locks open or

closed? ( ) Yes ( ) No

19. Do you chew gum?

( ) Yes ( ) 0-25%of waking hours ( ) 50-75% of waking hours
( ) No ( ) 25-50% of waking hours ( ) 75-100% of waking hours

20. Have you noticed any other oral habits or practices that aggravate or cause
pain? ( ) Clenching ( ) Grinding the
teeth
( ) Chewing ice ( ) Chewing finger nails
( ) Chewing pencil/paper clips ( ) Chewing cheeks/lips
( ) Holding phone between ear and shoulders ( ) Playing wind instruments/violin
( ) Other

21. Check all of the following that apply to you:

( ) Feel I am under stress mush of the time
( ) Stress makes the pain worse
( ) Do not enjoy my job
 ( ) The pain prevents me from performing my normal
activities
( ) There are times when I feel as though I cannot
breathe in enough air
( ) My hands and feel are often cold or hand to keep
warm ( ) Feel depressed much of the time ( ) Feel
lightheaded or dizzy
( ) have been under the care of psychiatrist or a
psychologist

22. Check all of the following that apply to you

: ( ) Do not sleep
well
( ) the pain interferes with
sleep
( ) Awaken frequently during the night
( ) Restless sleeper
( ) Vivid dreams or
nightmares
( ) Go to bed more tired than daily activities
justify
( ) Do not feel rested in the
morning
23. Do you feel that you usually eat healthy, balanced
diet? ( ) Yes ( ) No

24. For each of the beverage listed below, write in the average number that you will drink each

day: Natural coffee cups/day alcoholic beverages drinks/cans/day

Decaffeinated coffee cups/day soft drink cans/bottles/day
Natural Tea cups/day Other(specify)_ cans/bottles/day
Decaffeinated tea cups/day
Fruit juice cups/day
Water cups/day

25. What types of health care providers have you seen for your problem?
( ) None ( ) Rheumatologist ( ) General Dentist
( ) Rehabilitation medicine ( ) Physical medicine ( ) Oral surgeon
( ) Pain clinic ( ) Anesthesiologist ( ) Orthodontist
( ) TMJ specialist ( ) Osteopathic physician ( ) Ophthalmologists
( ) Internist ( ) Neurologist ( ) Chiropractor
( ) Ears, nose, throat physician ( ) Physical therapist ( ) Neurosurgeon
( ) Orthopedic surgeon
( ) Others describe
 26. Please list the names of the above health care providers :

27. Which of the following treatment(s) have you received for you pain:
( ) Traction ( ) Splints or bite lanes ( ) Electrical stimulants (TENS)
( ) Injections ( ) Counseling ( ) Ultrasound or lontophoresis
( ) Acupuncture ( ) Medications ( ) Root canal/dental treatment
( ) Massage ( ) Heat/cold applications ) Exercise
( ) Nerve blocks ( ) Acupressure ( ) Occlusal /bite Adjustment
( ) Biofeedback ( ) Stress management ( ) TMJ surgery
( ) Pain program ( ) Drug/alcohol rehab ( ) Orthodontics/braces
( ) Hypnosis ( ) Chiropractic treatment
Other
28. Which tests have you had for the problem?
( ) x-rays ( ) myelogram ( ) tooth pulp test
( )EMG ( ) MR scan ( ) urine studies
( ) Venogram ( ) arteriogram ( ) blood studies
( ) Joint arthrogram ( ) nerve block ( ) CT scan
( ) TMJ x-ray ( ) diet analysis ( ) thermogram
( ) Other

29. Do you smoke? ( ) No ( ) yes If so how much? Pack(s)/day

30. Are you receiving or applying for disability? ( ) Yes ( ) No

31. Have you or will you consult a lawyer regarding your pain
problem? ( ) Yes ( ) No
 General Medical History

Pease check the box for any condition which you have had in the past or have now.

1) CARDIOVASCULAR 4) GASTROINTESTINAL 8) GENITOURINARY

Congestive Heart Failure Stomach/Intestinal Urinate Frequently
Heart Attack Ulcers Kidney, Bladder Problem
Angina pectoris or Chest pain Colitis Dialysis
High Blood Pressure Persistent Diarrhea Kidney Transplant
Heart Murmur Hepatitis Sexually Transmitted

Mitral Valve Prop apse Liver Disease Disease (SYPHILIS,

Rheumatic Fever Yellow Jaundice Gonorrhea, Chlamydia or
Congenital Heart Defect Cirrhosis Genital Herpes
Artificial (Prosthetic) Eating Disorder HIV Positive
Heart Valve Multiple Sexual Partners
Arrhythmias 5.PULMONARY
Heart Pacemaker Hay Fever 9) OTHER CONDITIION
Defibrillator Sinus Trouble Frequent Sore Throats
Coronary By- Pass Allergies or Hives Enlarged lymph Node or
Coronary Angioplasty Asthma “Gland”
Heart Transplant Chronic Cough Use Tobacco
Aneurysm Emphysema Use Alcohol
Other Heart Problem chronic Bronchitis use Injectible Drugs
Drug or Alcohol Addiction
2) HEMATOLOGIC 6) DERMAL/MUSCULOSKELETAL
Blood Transfusion Allergy to relax (Rubber) (Recovering or Current)
Anemia Skin Rash Tumor or cancer
Hemophilia Dark Mole(s) Recent Radiation Therapy
Leukemia changes in appearance Chemotherapy
Sicke Cell Anemia Night Sweats Disease, Problerm or
Tendency to bleed Osteoarthritis Condition not listed
Longer than Normal Rheumatoid Arthritis If yes, list
systemic lupus
Artificial (Prosthetic) joint
 3) NEUROLOGIC 7) ENDOCRINE
Vision Problems Diabetes
Glaucoma Thyroid Disease
Earaches, Ringing in Ears Taking Cortisone or
Hearing Loss Other Steroid
Severe Headaches
Fainting & Dizzy Spells
Stroke
Epilepsy, seixures
Convulsion
Psychiatric Treatment
Panic attacks
Phobias

10. Who is your physician?

Physician’s addres

Phone# Last Appointment Date

What problem is your physician treating?

YES NO

11. Are you taking (or supposed to be taking) any medicine, drugs or pills of any kind
If yes, what kind and dose

12. Do you have reactions or allergies to drugs or medicines? What kind

13. Have you had an adverse reaction to dental or general anesthetic?

14. Have you ever had any operations or surgery?

 Describe the problem and any complications

15. When you walk up stairs or take a walk, do you ever have to stop because of pain in
your chest, shortness of breath, or because you are very tired

16. Do you ankles swell during the day?

17. Have you unintentionally lost or gained more than 10 pounds

18. Are you on a special diet?

19. (WOMEN) Are you pregnant, or possibly pregnant?