Tmj – facial pain questionnaire

TMJ – Facial Pain Questionnaire
Name:________________________________ Referred by:___________________________ Age:______ Date:__________
HISTORY
I. Chief Complaint (Describe your problem in your own words):

II. Symptoms Total length of time some or all TMJ/Facial pain symptoms present:___________________________________
 Pain: Right Left Both Sides
Location:
Temporal Region Cheek Region Lower Jaw Ear TMJ Region (in front of ear) Neck Shoulders Teeth Other________________________ Duration/Timing: worse in the Morning Afternoon Evening
Constant Intermittent Worse after eating/talking Joint Noises: Popping/clicking: Right Left Bilateral
Grinding: Right Left Bilateral Limited mouth opening: Persistent Intermittent Difficulty opening mouth Sleeping
Difficulty closing mouth Chewing Yawning or laughing Jaw locking episodes: Locked open Locked closed How often?__________
Headaches: Right Left Bilateral Frontal (forehead) Temporal (side of head) Occipital (back of head)
Ringing in Ears: Right Left
Fullness in Ears: Right Left
 Dizziness Visual Changes Change in hearing
Other__________________________________________________________________________________________
III. Possible Contributing Factors
 Facial Trauma/Injury___________________________________________________________________________
 Whiplash/Cervical Trauma___________________ ___________________________________________________
 Bruxism (grinding teeth)
Arthritis
Sleep Disorder_________________________________________
Stress
IV. Other Diagnosis and Treatment
Have you tried?
Panoramic Radiograph TMJ Tomograms MRI of TMJ region Have you been prescribed a bite splint or night guard? Yes No
If yes, do you use it? Always Occasionally Rarely/Never V. Medications
□ Non steroidals (such as Advil, Tylenol, Aleve) □ Muscle Relaxers (such as Flexeril, Soma, Robaxin) How often? □ Sleep Meds/Anti-depressants/Anti-Anxiety? How often? VI. Previous Treatment
Oral Surgeon:____________________________ Others:_________________________________ “Complete Back Side”
Spinal & Sports Care Clinic, 12905 E. Sprague Avenue, Spokane Valley, WA (509) 922-0303
1. Put an X on the line to rate your current level of jaw/headache pain: 0 ----------------------------------------------------------------------- 10 2. Put an X on the line to rate your current level of neck pain: 0 ----------------------------------------------------------------------- 10 3. On the diagram below, please shade the areas of your pain: 4. Please check medications you are taking for TMJ/facial pain/headaches: □ Non steroidals (such as Advil, Tylenol, Aleve) How often? □ Muscle Relaxers (such as Flexeril, Soma, Robaxin) How often? □ Sleep Meds/Anti-depressants/Anti-Anxiety? How often?

Source: http://spinalandsportscare.com/wp-content/uploads/2013/09/TMJ-patient-history-09-03-13.pdf