Patient Information Form
First Name:
Middle Initial:
Last Name:
Patient's Dentist:
Date of last visit:
Referred by:
What is your main reason for being here today?
Please check Yes or No: (if Yes, please fill in details):
Do you have a clicking, popping, or grating noise in:
Your right jaw joint?
Yes
No
Your left jaw joint?
Yes
No
When did you first notice the noise?
Has the noise recently become more pronounced?
Yes
No
When?
Has the noise ever disappeared?
Yes
No
When?
Do you have pain in or around:
Your right jaw joint?
Yes
No
Your left jaw joint?
Yes
No
When did you first notice the pain?
Has the pain recently become more pronounced?
Yes
No
When?
Is the pain worse:
Mornings
Evenings
At meals
No specific time
Is the pain:
Dull
Throbbing
Stabbing
Continuous
Intermittent
Other
Other:
Does the pain sometimes feel like it is in your ears?
Yes
No
Do you think this problem has affected your hearing?
Yes
No
Does your jaw problem interfere with your normal activities?
Yes
No
Explain:
Are you taking or have you taken medication for this problem?
Yes
No
Explain:
Do you have frequent headaches or neckaches?
Yes
No
What area(s)?
How Frequent?
How do you control pain?
Have you ever had a severe blow or trauma to the head, neck, or jaw?
Yes
No
Where?
Explain:
Do you have difficulty chewing?
Yes
No
Because of:
Pain in Joint
Limited Opening
Pain in Teeth
Missing Teeth
Clicking
Other:
Other:
Has your mouth ever locked open so that you were unable to close it?
Yes
No
Explain:
Has your mouth ever locked closed?
Yes
No
Explain:
Do you experience ringing or other sounds in the ears?
Yes
No
Explain:
Which aspects of your problem concern you the most?
Are you aware of clenching your teeth?
Yes
No
When?
Do you grind your teeth?
Yes
No
When?
Do you think nervous tension seems to affect this problem?
Yes
No
Explain:
Have you had problems with other joints?
Yes
No
Explain:
Have you had orthodontic treatment?
Yes
No
When?
Doctor:
Have you had recent dental treatment?
Yes
No
When?
Doctor:
Explain:
Have you had x-rays taken for this problem?
Yes
No
When?
Have you received previous treatment for this problem?
Yes
No
When?
Doctor:
Explain:
Is there any litigation (past or future) associated with this problem?
Yes
No
Explain:
Do you have allergies?
Yes
No
Envorimental (such as foods, animals, plantns, chemicals)
Medical (such as drugs, anesthetics, iodine - IVP dye)
Explain:
Have you ever had a reaction to medication other than allergic in nature?
Yes
No
Explain:
Have you ever been treated for any mental or emotional problems?
Yes
No
Explain with dates:
Do you suffer from stomach troubles or ulcer problems?
Yes
No
Are you suffering from rheumatism or arthritis?
Yes
No
Which type?
Rheumatoid
Degenerative
Traumatic
Gout
Other
Other:
Do your muscles and joints ever feel stiff or swollen?
Yes
No
Do you ever experience muscle aches or spasms?
Yes
No
Where?
Do you have trouble sleeping?
Yes
No
If yes, do you use sleeping pills?
Yes
No
Do you suffer from low back pain?
Yes
No
Do your salivary glands ever hurt or swell?
Yes
No
Have you ever had dental pain or infection?
Yes
No
Explain:
Have you had your wisdom teeth removed?
Yes
No
Do you have any eye problems?
Yes
No
Blurred Vision
Double Vision
Spots
Pain behind the eyes
Other
Other:
Do you wear glasses, contact lenses?
Yes
No
Have you had eye surgery?
Yes
No
Do you have sinus problems?
Yes
No
Does it hurt to open wide?
Yes
No
Do you chew exclusively on one side?
Yes
No
Does your bite feel uncomfortable?
Yes
No
Are you currently under extra stress?
Yes
No
At home
At work
Explain:
Social History:
Employment:
Marital Status:
Children?
Yes
No
Ages:
Use of tobacco/alcohol:
Use of Aspirin, Tylenol, etc.
Yes
No
Tablets per day:
Other life stress situations:
Habits:
Chew gum?
Yes
No
Frequency:
Chew tobacco?
Yes
No
Frequency:
Bite on foreign objects?
Yes
No
Pens
Pencils
Pipe
Fingernails
Other
Other:
Cradle the telephone in between neck and shoulder?
Yes
No
Right
Left
Rest chin in palm?
Yes
No
Right
Left
Sleeping Posture:
On stomach with head to right
On stomach with head to left
On back with head too high
On side with head too high
On right side
On left side