[Secure Form] Dev- Patient Information Form -TMD/OFP

Patient Information:

Last Name: *

First Name: *

Age: *

Sex:

Female

Male

1. What areas of TMD concern you the most?

2a. How many days/weeks/months/years ago did this problem begin?

2b. At what age?

3a. Please indicate areas of pain by drawing on the figures below:

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3b. Please indicate areas of pain by drawing on the figures below:

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3c. Please indicate areas of pain by drawing on the figures below:

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4. From the time you begin experiencing pain, please indicate how long the pain lasts:

5. Pain attack frequency (indicate continuous if there are no pain-free periods):

6. On a scale from 1 (no pain) to 10 (worst pain), please indicate the severity of your pain:

7. Please indicate factors that precipitate and/or aggravate your TMD pain:

8. Please indicate methods and/or medications you currently utilize to ease your TMD pain:

9. Please indicate how you would describe this pain (Check all that apply):

Pressing

Piercing

Throbbing

Burning

Electric

Sharp

Other

Other:

11. Is there a history of trauma?

Yes

11b. If yes, indicate date:

11c. Please indicate a description of trauma:

12. Has your condition interfered with any aspects of your life?

Yes

12b. If yes, please check all that apply:

Work / Physical activities

Emotions / Sexual activity

Family / Social activities

Weight Gain / Loss

Chewing / Swallowing

Sleep

Other

Other:

13. Does the TMD pain wake you during sleep?

Yes

14. Please list other doctors or healthcare professionals you have seen for your current problem. Also indicate treatment(s) recommended.

Other:

16. Do you have caffeine in your diet?

Coffee - Cups per day:

Tea/ Cola - Servings per day:

Chocolate - Servings per day:

Please add any information that you feel would be valuable for your care, diagnosis, and treatment:

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Last Name

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