TMJ SYNDROME AND MYOFASCIAL PAIN HEALTH HISTORY QUESTIONNAIRE

First Name:
Middle Initial:
Last Name:
Birthdate/Age:
Sex:
SSN or SIN:
Email:
Address:
City:
State:
Zip:

Emergency

Emergency Contact Name:
Relationship to patient:
Phone Number:

CHIEF COMPLAINT(S)

Describe what you think the problem is:
What do you think caused this problem?
Describe, in order (first to last), what you expect from your treatment:

MEDICAL AND DENTAL HISTORY

Physician's Name:
Date of Last Physical:
Patient Health:
Address:
City:
State:
Zip:
Please list any medications currently being taken by the patient (include non-prescription):
Please list any other drug allergies or sensitivities that the patient may have:
Please select 'Yes' if the patient has had any of the conditions listed below either now or in the past. Cannot be blank.
ADHD?
Anemia or blood disorder?
Arthritis or joint problems?
Asthma?
Autism spectrum disorder?
Bisphosphonates (Fosamax, Boniva)?
Bone disorders or loss?
Cancer?
Cancer in family history?
Cold sores?
Diabetes?
Emotional problems treatment?
Endocrine problems?
Growth problems?
Handicaps or disabilities?
Heart attack or stroke?
Heart defect (congenital)?
Heart disease?
Heart murmur?
Hemophilia?
Hepatitis?
High blood pressure or hypertension?
HIV or AIDS?
Hormone therapy?
Ever been hospitalized?
Kidney disease?
Latex or Metal Allergy?
Liver disease, jaundice, or hepatitis?
Nervous disorders?
Pneumonia?
Prolonged bleeding or transfusion?
Radiation treatment?
Rheumatic fever?
Seizures, epilepsy, or neurological disease?
Tonsils or adenoids removed?
Tuberculosis or lung disease?
If any of the above medical questions were answered 'Yes' , please explain:
Please list any other disorders or conditions not listed above:
Dentist's Name:
 Have you had any major dental treatment in the last two years?
If yes, please mark procedure(s):
Date(s) of Third Molar (wisdom tooth) extraction(s):

HISTORY OF INJURY AND TRAUMA

 Is there any childhood history of falls, accidents of injury to the face of head?
Describe:
 Is there any recent history of trauma to the head or face? (Auto accident, sports injury, facial impact)?
Describe:
 Is there any activity which holds the head or jaw in an imbalanced position? (Phone, swimming, instrument)
Describe:

FACIAL PAIN PAST TREATMENT

 Have you ever been examined for a TMD problem before?
If yes, by whom? When?
What was the nature of the problem? (Pain, noise, limitation of movement):
What was the duration of the problem? Months? Years?
 Is this a new problem?
Is the problem getting better, worse, or staying the same?
 Have you ever had physical therapy for TMD?
If yes, by whom? When?
 Have you ever received treatment for jaw problems?
If yes, by whom? When?
What was the treatment? (Please mark below)
If other, please explain:
 Have you ever had injections for your TMD with muscle relaxants (Botox, Flexeril) cortisone or anti-inflammatories?
 If yes, were they effective?
How many dental appliances have you worn?
 Were these appliances effective?
Is there any additional information that can help us in this area?

CURRENT STRESS FACTORS (PLEASE MARK EACH FACTOR THAT APPLIES TO YOU)

CURRENT AND PREVIOUS HABITS

 Do you clench your teeth together under stress?
 Do you grind/clench your teeth at night?
 Do you sleep with an unusual head position?
 Are you aware of any habits or activities that may aggravate this condition?
Describe:

CURRENT SYMPTOMS (PLEASE MARK EACH SYMPTOM THAT APPLIES)

A. HEAD PAIN, HEADACHES, FACIAL PAIN
Forehead
Temples
B. EYE PAIN / EAR ORBITAL PROBLEMS
C. MOUTH, FACE, CHEEK & CHIN PROBLEMS
D. TEETH & GUM PROBLEMS
E. JAW & JAW JOINT (TMD) PROBLEMS
F. PAIN, EAR PROBLEMS, POSTURAL IMBALANCES
G. NECK & SHOULDER PAIN
H. THROAT PROBLEMS
I. OTHER PAIN