HEAD, NECK AND FACIAL PAIN QUESTIONNAIRE
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- Gerald Pierce
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1 HEAD, NECK AND FACIAL PAIN QUESTIONNAIRE Form 401A This questionnaire was designed to provide important facts regarding the history of your pain or condition. The information you provide will assist in reaching a diagnosis. Please take your time and answer each question as completely and honestly as possible. Please sign each page. PATIENT INFORMATION TODAY'S DATE q MR. EMS. q MISS H MRS. E DR. NAME: First Middle Initial Last AGE: BIRTH DATE: q MALE q FEMALE ADDRESS: EMPLOYED BY: ADDRESS: SS#: CELL PHONE: CITY/STATE/ZIP: HOME PHONE: WORK PHONE: MARITAL STATUS: E Single q Married q Widowed q Divorced RESPONSIBLE PARTY: FAMILY DENTIST: FAMILY PHYSICIAN: ADDRESS: ADDRESS REFERRED BY: WHAT ARE THE CHIEF COMPLAINTS FOR WHICH YOU ARE SEEKING TREATMENT? 1. Please number your complaints with #1 being the most severe symptom, #2 the next, etc. 2. Then rate your complaints for frequency and intensity: Frequency: (1- SELDOM, 2-OCCASIONAL, 3- FREQUENT, 4- EVERY DAY) Intensity: (0 is NO PAIN and 10 is MOST SEVERE PAIN) Number Frequency Intensity #1 = the most severe symptom Back Pain Dizziness Ear Congestion Ear Pain Eye Pain Facial Pain Fatigue Headaches Inability to open mouth Jaw Clicking Jaw Joint Noises Jaw Locking Jaw Pain Limited Mouth Opening Migraine Headaches Muscle Twitching Neck Pain Pain when Chewing Ringing in the Ears Shoulder Pain Sinus Congestion Throat Pain Visual Disturbances Other - write in: 2006 TMJ PRACTICE MANAGEMENT ASSOCIATES, INC REPRINT RIGHTS ONLY THROUGH LICENSING
2 Form 401A - Page 2 LIST ANY MEDICATIONS/SUBSTANCES WHICH HAVE CAUSED AN ALLERGIC REACTION: YD Antibiotics YD y D Aspirin Yq YO Barbiturates YD YO Codeine YD Y q Iodine Y q Latex Local anesthetics Metals Penicillin Plastic YE] Sedatives YD Sleeping pills YO Sulfa drugs YD Other LIST ANY MEDICATIONS CURRENTLY BEING TAKEN: yq YO NO y0 NO YE] YO ND Antibiotics Anticoagulants Barbiturates Blood thinners Codeine YE N E] Yq N E] YO YD Y q Cortisone Diet pills Heart medication Insulin Muscle relaxants YE] N 11 YD YE YD yq Nerve pills Pain medication Sleeping pills Sulfa drugs Tranquilizers Other PLEASE LIST ANY TREATMENTS YOU HAVE HAD FOR THIS PROBLEM AND ALL HEALTH PROFESSIONALS THAT YOU ARE CURRENTLY SEEING: Practitioner Specialty Treatment & approximate date MEDICAL HISTORY (Please indicate dates on questions checked YES) YO Adenoids Removed YD ND Tonsils Removed Yq Anemia YO Arteriosclerosis Y q NO Asthma YE] NO Autoimmune disorders YE] ND Bleeding easily YE] NE] Blood pressure q High q Low YO Bruising easily Y q Cancer YE] ND Chemotherapy YD Chronic fatigue YD Cold hands & feet Yq Current pregnancy YD Depression YE) Diabetes YO Difficulty concentrating Y q Dizziness YE] NO Emphysema YD Epilepsy YE] Excessive thirst YD Fluid retention Yq Frequent cough YO Frequent illnesses YO Frequent stressful situations Y q Fibromyalgia Y111 Yq YE] N E] YO YE] NE] YE] ND Yq NE] YE! ND YE] NE] Yq NE] YE] NE] YE] NE NE] General anesthesia Glaucoma Gout Hay fever Hearing impairment Heart murmur Heart disorder Heart pacemaker Heart palpitations Heart valve replacement Hemophilia Hepatitis Hypoglycemia 2006 TMJ PRACTICE MANAGEMENT ASSOCIATES, INC REPRINT RIGHTS ONLY THROUGH LICENSING.
3 MEDICAL HISTORY CONTINUED YD Immune system disorder N E Injury to q Face Mouth q Neck q Teeth YD Insomnia YE] Intestinal disorders yq N E] Jaw joint surgery y E Kidney problems YE] N E] Liver disease Meniere's disease Menstrual cramps Y q Multiple sclerosis Muscle aches y q Muscle shaking (tremors) N D Muscle spasms or cramps Other YE N E Muscular dystrophy y q NE Needing extra pillows to help breathing at night N El Nervous system irritability YE N E] Nervousness Neuralgia YE Osteoarthritis yq Osteoporosis Ovarian cysts YE Parkinson's disease YE] N[1] Poor circulation N[j] Prior orthodontic treatment N E Psychiatric care yq N El Radiation treatment yq Rheumatic fever Rheumatoid arthritis Scarlet fever Form 401A - Page 3 YE N D Shortness of breath YE Sinus problems E N E] Skin disorder Y q Slow healing sores y E Speech difficulties yq Stroke yq Swollen, stiff or painful joints N E] Tendency for: y q Y q Y q YE] Y q 11] Frequent Colds q Ear Infections q Sore Throats Tired muscles Tuberculosis Tumors Urinary disorders Wisdom teeth (Third Molar) extraction SYMPTOMS: PLEASE INDICATE LOCATION AND TYPE OF ANY HEAD PAIN L= Left R=Right B=Both sides SEVERITY FREQUENCY DURATION HEAD PAIN LOCATION JAW PAIN B Front of your head (Frontal) q B Entire head (Generalized) B Top of your head (Parietal) q B Back of your head (Occipital) q B In your temples (Temporal) q B Jaw pain - on opening B Jaw pain - while chewing B Jaw pain - at rest JAW SYMPTOMS YE Jaw clicks YE Jaw locks closed YE Jaw locks open YD Jaw popping YE] Teeth clenching YO Teeth grinding OCCASIONAL CONSTANT MODERATE (MONTHLY FREQUENT (EVERY MILD I SEVERE OR LESS) (WEEKLY) DAY) SECONDS MINUTES HOURS DAYS WEEKS q EYE RELATED CONDITIONS YE ND Blurred vision YE NE] Double vision YD E] Eye pain Pain or pressure behind the eyes YE NE Photophobia (extreme sensitivity to light) q q q q 117 q q q q q q q q q q q q q q q q q q EAR RELATED CONDITIONS YEI YD ND YE] NE YE NE YE E q E N y q NE Buzzing in the ears Ear congestion Ear pain Hearing loss Pain behind the ear Pain in front of the ear Recurrent ear infections Tinnitus (ringing in the ear) THROAT NECK & BACK RELATED CONDITIONS YE Back pain - lower y q N111 Back pain - middle YE] Back pain - upper YO Chronic sore throat q YE] N Constant feeling of a foreign object in throat YD N D Difficulty in swallowing YE Limited movement of neck q YE N Neck pain YE Numbness in the hands or fingers 2006 TMJ PRACTICE MANAGEMENT ASSOCIATES, INC. REPRINT RIGHTS ONLY THROUGH LICENSING.
4 THROAT NECK & BACK RELATED CONDITIONS (Continued) MOUTH & NOSE RELATED CONDITIONS YD Sciatica yq NE Broken teeth YE] Scoliosis y q NE Burning tongue N D Shoulder pain YE] NE Chronic sinusitis Shoulder stiffness y q NE Dry mouth YE N D Swelling in the neck y NE Frequent biting of cheek YE] Swollen glands y q Frequent snoring YE] Thyroid enlargement YD Tightness in throat Other YE Tingling in the hands or fingers YD N D Wryneck Form 401A - Page 4 HISTORY OF SYMPTOMS When did your condition first occur? What do you believe is the cause of your pain or condition? Pick one: q Motor vehicle accident q Motorcycle accident q Athletic endeavor q Fight Ei Fall q Unknown If accident, date Is there anything that makes your pain or discomfort worse? q Work related incident q Playground incident q Accident q Illness q Injury Is there anything that makes your pain or discomfort better? What other information is important to your pain or condition? FAMILY HISTORY Have any members of your family (blood kin) had: Headaches Yq High blood pressure Heart disease Yq Diabetes SOCIAL HISTORY Occupation Do you have children? Yq If yes, how many children? YE Are you currently under unusual stress? Recent change in lifestyle? Do you exercise regularly? What are their ages? YE Do you chew tobacco? Number of caffeine drinks per day YD Do you smoke? Alcohol consumption Number of q Packs q Cigarettes per q Day q Week q None q Occasional q Social Drinker q Daily 2006 TMJ PRACTICE MANAGEMENT ASSOCIATES, INC REPRINT RIGHTS ONLY THROUGH LICENSING.
5 DRAW YOUR PAIN PATTERNS FOLLOWING THIS KEY: MILD PAIN MODERATE PAIN SEVERE PAIN B Burning D Dull N Numbing P Pressure S Sharp T Tingling R Radiating EXAMPLE Form 401A - Page 5 Form TMD-Sleep Mild, numbing pain Moderate, dull pain Severe, radiating pain Pressure RIGHT LEFT 2006 TMJ PRACTICE MANAGEMENT ASSOCIATES, INC REPRINT RIGHTS ONLY THROUGH LICENSING
6 HISTORY OF ACCIDENT Form 401A - Page 6 IF YOU WERE INVOLVED IN AN ACCIDENT OR A TRAUMATIC INCIDENT, COMPLETE THIS SECTION. DATE OF ACCIDENT OR INCIDENT WERE YOU? q A passenger in a vehicle A pedestrian q At work IF IN A VEHICLE WHERE WAS THE VEHICLE HIT? At front end At rear end At front right area At front left area At rear right area q At rear left area AND... q Did you fall? Did you hit an object? (Choose one) q The driver of a vehicle (Choose one) q Were you hit by an object? INDICATE IF THERE WAS ANY DIRECT TRAUMA. DID YOUR Forehead Face Chin Side of head Back of head Top of head Teeth Jaw Head on On drivers side On passengers side FORCIBLY STRIKE Steering wheel Windshield Passengers side window Driver's side window Passenger's side door Driver's side door Headrest Seat Roof Interior of car WERE ANY AREAS OF YOUR BODY PAINFUL SHORTLY AFTER THE ACCIDENT/INCIDENT? Head Left arm Neck Right arm Face Lower back Jaw Upper back Left shoulder : q Right shoulder BRIEFLY DESCRIBE THE HISTORY OF SYMPTOMS, ACCIDENT OR INCIDENT: DID YOU GO TO THE HOSPITAL? Ei Yes q No 111 By Car q q TAKEN TO THE HOSPITAL FOR X-RAYS & EVALUATION By Ambulance WERE YOU q SUBSEQUENTLY RELEASED ON () WHICH HOSPITAL? HAD A DOCTOR OR DENTIST EVER DIAGNOSED A TMJ DISORDER PRIOR TO THE ACCIDENT? q Yes II] No If yes, please explain 2006 TMJ PRACTICE MANAGEMENT ASSOCIATES, INC. REPRINT RIGHTS ONLY THROUGH LICENSING
7 IF YOU HAD A PREVIOUS ACCIDENT, PLEASE GIVE AN ACCURATE DESCRIPTION, Form 401A - Page 7 INCLUDING DATE: NAMES AND ADDRESSES OF HOSPITALS AND DOCTORS WHERE TREATED FOR THIS PREVIOUS ACCIDENT: IF YOU HAVE MISSED ANY WORK PLEASE GIVE DATES: INSURANCE INFORMATION AUTO INSURANCE Please mark each insurance category q your insurance 0 driver of vehicle's insurance Insured Relationship Insured's Address Insurance Co. Insurance Billing Address Policy No. Claim No 0 other vehicle's insurance owner of vehicle's insurance Insured's Soc. Sec. No. Adjuster (not agent) Phone No. OTHER TYPES OF INSURANCE HEALTH INSURANCE (Complete even if you are covered by auto insurance) Insured Insured's Soc. Sec. No. Relationship Insured's Address Has this been reported? q Yes No Insurance Co. Adjuster (not agent) Phone No. Insurance Billing Address Policy No. WORKER'S COMPENSATION Employee Address Group No. I.D. No Employer Phone No. Supervisor Has this been reported? Yes No If yes, was treatment authorized? Insurance Co. Insurance Billing Address Policy No Group No. I.D. No. If you have additional insurance, please enter the information on the reverse side of this form TMJ PRACTICE MANAGEMENT ASSOCIATES, INC REPRINT RIGHTS ONLY THROUGH LICENSING.
8 Form 401A - Page 8 ATTORNEY INFORMATION If you have an attorney representing you, please complete the following: Attorney's Name Paralegal Address Phone No. Are you involved in a lawsuit regarding your condition? n Yes No I authorize the release of a full report of examination findings, diagnosis, treatment program, etc., to any referring or treating dentist or physician. I additionally authorize the release of any medical information to insurance companies or for legal documentation to process claims. I understand that I am responsible for all charges for treatment to me regardless of insurance coverage. FOR OFFICE USE ONLY Insurance Company Group Health Auto Government Self Insured Dental Contact Person Effective date of this policy TMJ policy exclusions Amount of deductible? Has it been satisfied? At what percentage are benefits paid? Is there a policy maximum for TMJ disorders? Is precertification required Can benefits be assigned to doctor? q Yes No What information is needed to process the claim? For No Fault: Amount of benefits Mailing Address Adjuster By Assignment approved q Yes q No 2006 TMJ PRACTICE MANAGEMENT ASSOCIATES, INC REPRINT RIGHTS ONLY THROUGH LICENSING
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