TMJ SYNDROME AND MYOFASCIAL PAIN HEALTH HISTORY QUESTIONNAIRE

    CHIEF COMPLAINT(S)

    1) Have you had any major dental treatment in the last two years? (Circle one)

    If yes, please mark procedure(s):

    HISTORY OF INJURY AND TRAUMA

    1) Is there any childhood history of falls, accidents of injury to the face of head?

    2) Is there any recent history of trauma to the head or face? (Auto accident, sports injury, facial impact)

    3) Is there any activity which holds the head or jaw in an imbalanced position? (Phone, swimming, instrument)

    FACIAL PAIN PAST TREATMENT

    1) Have you ever been examined for a TMD problem before?

    Is this a new problem?

    6) Have you ever had a physical therapy for TMD?

    7) Have you ever received treatment for jaw problems?

    What was the treatment? (Please mark Below)

    8) Have you ever had injections for your TMD with muscle relaxants (Botox, Flexeril) cortisone or anti-inflammatories?

    9) Were these appliances effective?

    CURRENT SYMPTOMS?

    1) Are you taking medication for the TMD problems?

    2) Are the medications that you take effective?

    CURRENT STRESS FACTORS (PLEASE MARK EACH FACTOR THAT APPLIES TO YOU)

    CURRENT AND PREVIOUS HABITS (PLEASE MARK YOUR ANSWER TO EACH QUESTION)

    CURRENT SYMPTOMS (PLEASE MARK EACH SYMPTOM THAT APPLIES)

    For items with an option of L and R you must select either L for Left Side, R for Right Side or both L and R for both sides of your face or body if noting Degree of Pain, Frequency, or Time of Day for those items.

    A. HEAD PAIN, HEADACHES, FACIAL PAIN

    Degree of Pain

    1. 1. Mild
    2. 2. Moderate
    3. 3. Severe

    Frequency

    1. 1. Daily
    2. 2. Monthly
    3. 3. Yearly

    Time of Day

    1. 1. Morning
    2. 2. Afternoon
    3. 3. Night

    Migraine Type Headaches L R

    Cluster Headaches Maxillary Sinus L R

    Headaches (under the eyes)
    Occipital Headaches (back of the head with or without shooting pain)
    Hair and/or Scalp Painful to Touch

    B. EYE PAIN /EAR ORBITAL PROBLEMS

    Blood shot eyes L R

    Pressure behind eyes L R

    Light Sensitivity

    Clicking, popping L R

    Grating sounds L R

    Pain in Cheek Muscles L R

    Hissing, buzzing, ringing sounds L R

    Ear pain without infection L R

    Diminished ear L R

    Arm and finger tingling L R

    C. JAW & JAW JOINT (TMD) PROBLEMS

    Clicking, Popping Jaw Joints L R

    Grating Sounds L R

    Jaw Locking Opened L R

    Jaw Locking Closed L R

    Uncontrollable Jaw/Tongue Movements L R

    Pain in Cheek Muscles L R

    D. PAIN, EAR PROBLEMS, POSTURAL IMBALANCE
    Ear Pain without Infection
    Clogged, Stuffy, Itchy Ears
    Balance Problems Vertigo
    Diminished Hear

    E. NECK & SHOULDER PAIN

    Arm and Finger Tingling, Numbness, Pain L R

    Reduced Mobility and Range of Motion L R

    Stiffness L R

    Neck Pain L R

    Tired, Sore Neck Muscle L R

    Back Pain, Upper and Lower L R

    Shoulder Aches L R

    F. THROAT PROBLEMS
    Swallowing Difficulties
    Tightness of Throat
    Sore Throat
    Voice Fluctuations