Section 1 of 1 in this document
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:
10. Please check all accompanying signs and symptoms:
Headache
Dizziness
Nausea
Tearing
Photophobia
Swelling
Phonophobia
Rhinorrhea
Vomiting
Redness
11. Is there a history of trauma?
Yes
No
11b. If yes, indicate date:
11c. Please indicate a description of trauma:
12. Has your condition interfered with any aspects of your life?
Yes
No
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
No
14. Please list other doctors or healthcare professionals you have seen for your current problem. Also indicate treatment(s) recommended.
15. Have you ever had or currently have any of the following medical conditions? (Please check each one that applies)
Anxiety
Fainting spells
Depression
Fibromyalgia
Sleeping problems
Parkinson's
Nervous disorders
Huntington's
MS
Spasm
Headaches (tension)
Irritable bowel syndrome
Headaches (migrane)
Constipation
Muscle tension
Difficulty urinating
Cancer
Glucoma
Other
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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