WHAT ARE THE CHIEF COMPLAINTS FOR WHICH YOU ARE SEEKING TREATMENT?
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- Evelyn Fox
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1 This additional questionnaire was designed to draw out and document 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. Today's Date: Patient Full Name: WHAT ARE THE CHIEF COMPLAINTS FOR WHICH YOU ARE SEEKING TREATMENT? Please number your complaints with #1 being the most severe symptom, #2 the next, etc. Then rate your complaints for frequency and intensity: Frequency 1-SELDOM 2-OCCASIONAL 3-FREQUENT 4-EVERY DAY Intensity 0 is NO PAIN 10 is MOST SEVERE PAIN Number #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: Frequency 1-4 Intensity 0-10 Please list any treatments you have had for this problem and all health professionals that you are currently seeing: Practitioner Specialty Treatment & approximate date
2 SYMPTOMS: PLEASE INDICATE LOCATION AND TYPE OF ANY HEAD PAIN Head Pain Location Severity Frequency Duration Front of your head (Frontal) Entire head (Generalized) Top of your head (Parietal) Back of your head (Occipital) In your temples (Temporal) Mi - Mild Mo - Moderate Se - Severe O - Occasional F - Frequent C - Constant SS- Seconds, MM - Minutes HH - Hours, DD - Days, WW - Weeks Jaw Pain Ear Related Conditions Jaw pain on opening Buzzing in the ears Jaw pain while chewing Ear congestion Jaw pain at rest Ear pain Hearing loss Jaw Symptoms Pain behind the ear Jaw clicks Pain in front of the ear Jaw locks closed Recurrent ear infections Jaw locks open Tinnitus (ringing in the ear) Jaw popping Teeth clenching Teeth grinding Throat Neck & Back Related Conditions Back pain - lower Back pain - middle Eye Related Conditions Back pain - upper Blurred vision Chronic sore throat Double vision Constant feeling of foreugn object in throat Eye pain Difficulty in swalowing Pain or pressure behind the eyes Limited movement of neck Photophobia (extreme sensitivity to light) Neck pain Numbness in the hands or fingers Mouth & Nose Related Conditions Sciatica Broken teeth Scoliosis Burning tongue Shoulder pain Chronic sinusitis Shoulder stiffness Dry mouth Swelling in the neck Frequent biting of cheek Swollen glands Frequent snoring Thyroid enlargement Other: Tightness in throat Tingling in the hands or fingers
3 History Of Symptoms When did your condition first occur? What do you believe is the cause of your pain or condition? If accident, date: Is there anything that makes your pain or discomfort worse? Is there anything that makes your pain or discomfort better? What other information can you share that is important to your pain or condition? Family History Have any members of your family (blood kin) had: Headaches High blood pressure Heart Disease Diabetes Social History Occupation: Do you have children? If yes, how many children? What are their ages? Are you currently under unusual stress? Recent changes in lifestyle? Do you exercise regularly? Do you chew tobacco? Number of caffeine drinks per day Do you smoke? Number of per Alcohol consumption
4 USING THE IMAGE MAP, INDICATE YOUR PAIN PATTERNS IN THE TABLE LISTED NEXT TO EACH IMAGE Indicate your pain patterns in the sectional areas using the drop down boxes given below. Use the diagram on the left to refer to the sectional area. RIGHT LEFT R1 L1 R2 L2 R3 L3 R4 L4 R5 L5 R6 L6 R7 L7 Indicate your pain patterns in the sectional areas using the drop down boxes given below. Use the diagram on the left to refer to the sectional area. RIGHT LEFT R1 L1 R2 L2 R3 L3 R4 L4 R5 L5 R6 L6 R7 L7
5 Indicate your pain patterns in the sectional areas using the drop down boxes given below. Use the diagram to refer to the sectional area. P1 B1 F1 A1 P2 B2 F2 A2 B3 F3 A3 B4 F4 B5 F5 Indicate your pain patterns in the sectional areas using the drop down boxes given below. Use the diagram to refer to the sectional area. A1 F1 B1 P1 A2 F2 B2 P2 A3 F3 B3 F4 B4 F5 B5
6 HISTORY OF ACCIDENT Date of Accident or Incident Were you? And... If in a vehicle where was the vehicle hit? Indicate if there was any direct trauma Did your Forcibly strike Were any areas of your body painful shortly after the accident/ incident? Briefly describe the history of symptoms, accident or incident Did you go to the hospital? Taken to the hospital for X-Rays & Evaluation Were you Subsequently Released On (Date) Which Hospital? Had a Doctor or Dentist ever diagnosed a TMJ disorder prior to this incident? If Yes, please explain: If you had a previous accident, please give an accurate description, including date: Names and addresses of hospitals and doctors where treated for this previous accident: If you have missed any work please give dates:
7 AUTO INSURANCE Please mark your insurance category INSURANCE INFORMATION Insured Insured s Soc. Sec. No. Relationship Insured s Address Insurance Co. Adjuster (not agent) Phone No. Insurance Billing Address Policy No. Claim No. Has this been reported? 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 Insurance Co. Adjuster (not agent) Phone No. Insurance Billing Address Policy No. Group No. I.D. No. WORKER'S COMPENSATION Employee Address Employer Phone No. Supervisor Has this been reported? If yes, was treatment authorized? Insurance Co. Insurance Billing Address Policy No. Group No. I.D. No. Additonal Information ATTORNEY INFORMATION If you have an attorney representing you, please complete the following: Attorney s Name Paralegal Phone No. Address Are you involved in a lawsuit regarding your condition? 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. Patient Initials: Date:
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