Facial Pain, Headache and TMJ Questionnaire Date: Patient Name: 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 Name of Referring Doctor Address: Phone: Describe your chief complaint/how and when did it begin: (Reasons for being here): Please answer the following: 1. What is the average severity of your pain? (Circle the appropriate number) 0 1 2 3 4 5 6 7 8 9 10 No Pain Extreme pain 2. 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 2-A. Describe the way your pain typically feels: [ ] Throbbing [ ] Gnawing [ ] Splitting [ ] Shooting [ ] Hot/Burning [ ] Tiring-exhausting [ ] Stabbing [ ] Aching [ ] Sickening [ ] Sharp [ ] Heavy [ ] Fearful [ ] Cramping [ ] Tender [ ] Punishing Cruel 2-B. On the diagrams below please outline the areas where you feel pain. If there is more than one type of pain, label 1, 2, 3, etc. 1
2-C. Do you have any painful teeth or other painful areas in your mouth? If Yes, please circle the areas on the diagram. 2-D. 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 car for long period [ ] Sitting for long periods [ ] Singing [ ] Eating certain foods [ ] Exercise [ ] Other 2-E. Which of the following relieves the pain? [ ] Exercise [ ] Massage of the area [ ] Warm soak/compresses [ ] Heat [ ] Holding jaw in certain position [ ] Ice/cold compresses [ ] Sleep [ ] Moving/manipulating jaw [ ] Pain medication [ ] Time [ ] Relaxation [ ] Nothing helps [ ] Other 3. Check any of the following that you experience. [ ] Numbness in the face or jaw [ ] Weakness in jaw muscles [ ] Earache [ ] Ringing or buzzing in the ears [ ] Ear stuffiness [ ] Dizziness [ ] Neck pain [ ] Pain in back 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 fingers 4. Have you EVER been in an accident or received a blow or injury to any part of your face, head, neck or back? If yes, when? Describe the circumstances: 2
Headaches 5. Are you bothered by headaches or sinus headaches? Please answer these questions based on the type of headaches that interfere most with your daily activities. When you have a headache, how often do you. Have moderate to severe pain? Never Rarely Usually Always Have pulsating, pounding, or Never Rarely Usually Always throbbing pain? Have worse pain on one side of your Never Rarely Usually Always head? Have worse pain when you move or Never Rarely Usually Always Bend over? Have nausea? Never Rarely Usually Always Have sensitivity to or are bothered Never Rarely Usually Always by light? Have sensitivity to or are bothered by Never Rarely Usually Always sound? Need to limit or avoid daily activities? Never Rarely Usually Always Want to lie down in a quiet dark room? Never Rarely Usually Always See visual disturbances, spots or Never Rarely Usually Always light flashes? Feel them coming on before they Never Rarely Usually Always become a headache? Feel drained or too tired to want Never Rarely Usually Always to do daily activities? Feel a reduced ability to Never Rarely Usually Always concentrate? At what age did you first experience these headaches? 6. Do any immediate family members also suffer from headache? Please list YES NO 7. In your lifetime, have you had at least 5 headaches with the symptoms you noted above? YES NO Do you have headaches as often as once per week? Do you have more than one type of headache? 3
Do you wake up in the morning with a headache? Do you have headaches later in the day? Do headaches wake you up from sleep? Are there vision changes associated with your headaches? If yes, what kind? What relieves the headache? [ ] Rest [ ] Nothing [ ] Sleep [ ] Exercise [ ] Pain medications; which ones Jaws/TMJ 8. Has your jaw ever locked open? [ ] Yes [ ] Right side [ ] Both sides [ ] No [ ] Left side 9. Has your jaw ever locked closed? [ ] Yes [ ] Right side [ ] Both sides [ ] No [ ] Left side 10. How many times has your jaw locked open during the past year? [ ] None # of times 11. Do you have pain when your jaw locks open or closed? 12. Does your jaw make noises during mouth movements? Other 13. Describe your weekly exercise routine: 14. Check any that you do or have been told that you do: [ ] Clenching the teeth [ ] Grinding the teeth [ ] chewing ice [ ] Chewing finger nails [ ] Chewing pencil/paper clips [ ] chewing cheek/lips [ ] Holding phone between ear and shoulders [ ] Playing wind instruments/violin [ ] Chew gum 4
15. 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 [ ] Snoring that is confirmed by bed partner 16. How likely are you to doze off or fall asleep in the following situations, in contrast to feeling just tired? This refers to your usual way of life in recent times. Even if you have not done some of these things recently, try to work out how they would have affected you. Use the following scale to choose the most appropriate number for each situation. 0 = would never dose 1 = slight chance of dozing 2 = moderate chance of dozing 3 = high chance of dozing SITUATION CHANCE OF DOZING (0 3) Sitting and reading Watching television Sitting inactive in a public place (e.g. a theater or 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 the traffic 17. Do you feel that you usually eat a healthy, balanced diet? 18. Do you smoke? [ ] No [ ] Yes If so, how much? Pack(s)/day 19. For each of the following beverages listed below, write in the average number that you will drink each day: Natural coffee cups/day alcoholic beverage drinks/cans/day Decaffeinated coffee cups/day soft drink cans/bottles/day Natural tea cups/day other (specify) Decaffeinated tea cups/day cans/bottles/day Fruit juice cups/day Water cups/day 20. 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 [ ] Family physician [ ] Ophthalmologist [ ] Internist [ ] Osteopathic physician [ ] Chiropractor [ ] Ears, nose, throat physician [ ] Neurologist [ ] Neurosurgeon 5
[ ] Orthopedic surgeon [ ] Physical therapist [ ] Other, describe 21. Which of the following treatment(s) have you received for your pain: [ ] Traction [ ] Splints or night guard [ ] Electrical stimulation (TENS) [ ] Injections [ ] Counseling [ ] Ultrasound or iontophoresis [ ] 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 22. Which tests have you had for the problem? [ ] X-rays [ ] Myelogram` [ ] Tooth pulp test [ ] EMG [ ] MRI scan [ ] Urine studies [ ] Venogram [ ] Arteriogram [ ] Blood studies [ ] Joint arthrogram [ ] Nerve block [ ] CT scan [ ] TMJ x-ray [ ] Diet analysis [ ] Thermogram [ ] Other 23. Are you receiving or applying for disability? 24. ACCIDENT INFORMATION Is your complaint associated with an accident? [ ] YES [ ] NO AUTO? [ ] YES [ ] NO FIGHT? [ ] YES [ ] NO ON THE JOB ACCIDENT? [ ] YES [ ] NO (Whom were you employed with? OTHER? [ ] YES [ ] NO Date(s) of Accident(s) & Brief Description: 25. Have you or will you consult a lawyer regarding your pain problem? Over the last 2 weeks, how often have you More than been bothered by the following problems? Not Several half the Nearly at all days days very day 1. Feeling nervous, anxious or on edge 0 1 2 3 2. Not being able to stop or control worrying 0 1 2 3 3. Little interest or pleasure in doing things 0 1 2 3 4. Feeling down, depressed or hopeless 0 1 2 3 6
List all CURRENT PRESCRIPTION & OVER THE COUNTER MEDICATIONS Name & dosage of medication Medication taken for what condition Prescribing doctor s name (if applicable) Number of times per day How long have you been taking this medication? Indicate amount of relief from condition: E=Excellent F=Fair M=Minimal N=None List all PAST PRESCRIPTION and all PAST OVER THE COUNTER MEDICATIONS taken for your pain Name and dosage of PAST PRESCRIPTION medications Medication taken for what condition? Prescribing Doctor s Name Number of times per day How long had you been taking this medication? Why did you stop taking this medication? Indicate amount of relief from condition E=Excelle nt F=Fair M=Minim al N=None 7
THE NAMES OF YOUR CAREGIVERS ARE: Family Doctor: Family Dentist: Oral Surgeon: Neurologist/Neurosurgeon: Pain Management Physician: Orthopedic Surgeon: Cardiologist: Physical Therapist: ENT: Psychiatrist: Psychologist: Orthodontist: Other: PHARMACY PHONE NUMBER: Release of Medical Information o It is standard practice to supply a letter to the physician or dentist who referred you to our practice, as well as other physicians or dentists that may have evaluated you for your problem or may need to become involved with your care in the future (i.e. primary care physician or neurologist). This letter contains a description of your problem, medical history, examination results, test results, diagnosis and treatment recommendations. YOUR REFERRING DOCTOR WILL RECEIVE THIS LETTER Please list any additional doctors below that you would like to receive this letter. (Please supply all information) 1. Name 2. Name Address Address City State Zip City State Zip Phone # Fax # Phone # Fax # Signature of Patient Date 8