Dr. Jennifer Silver - Cosmetic Dentistry - Making better SmilesFREE CONSULTATION

Head, Neck, Facial and TMJ Pain Patient Questionaire Form

Gender
MaleFemale

INSURANCE INFORMATION (Must be completed before examination date)

Dental Insurance

Medical Insurance

If your condition / pain is due to a motor vehicle accident, please complete this section:

Motor Vehicle Insurance (registered owner of vehicle’s insurance)

Legal

We do not accept workers compensation claims.

Symptoms ( Please Check Any/All Symptoms that you have Experienced)
HeadacheNeck AcheHearing LossEaracheShoulder PainFacial PainEye PainNeck NoiseJaw Joint NoiseRinging, Buzzing EarsJaw/Facial Pain with ChewingJaw/Facial Pain with YawningLimited Jaw OpeningJaw LockingJaw FatigueJaw StiffnessFacial NumbnessFacial SwellingLimited Movement of NeckClenching TeethUncomfortable BiteCheek BitingEar CongestionDizzinessJaw Muscle TremorTeeth AcheJaw DislocatesSwelling in NeckBack PainTingling/Numbness in Hands/ArmsTinnitusDifficulty SwallowingInsomnia/SnoringBroken Teeth

Please indicate the location of your pain on the following diagrams. If your pain starts in one area but radiates to others, please indicate by writing it below with descriptions.

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Please list the 4 most important symptoms you wish to resolve them from the list







For each of the pains you have outlined, please indicate the words you feel best describe your pain.

Severity Mild Moderate Severe
Headache Mild Moderate Severe
Jaw ache Mild Moderate Severe
Neck pain Mild Moderate Severe
Shoulder pain Mild Moderate Severe
Facial pain Mild Moderate Severe
Frequency Mild Moderate Severe
Headache Mild Moderate Severe
Jaw ache Mild Moderate Severe
Neck pain Mild Moderate Severe
Shoulder pain Mild Moderate Severe
Facial pain Mild Moderate Severe
Duration Seconds Minutes Hours All day Weeks
Headache Seconds Minutes Hours All day Weeks
Jaw ache Seconds Minutes Hours All day Weeks
Neck pain Seconds Minutes Hours All day Weeks
Shoulder pain Seconds Minutes Hours All day Weeks
Facial pain Seconds Minutes Hours All day Weeks

Cause of Chief Concern

The initial cause of my problem was:
VIRALINFECTIONUPON AWAKENINGTOOTH EXTRACTIONSTRESSFUL PERIODPREGNANCYNEW DENTURESDENTAL WORKPHYSICAL FATIGUEILLNESSOTHER HEAD/NECK PAINVEHICLE ACCIDENTMENSTRUAL PERIODGRADUAL ONSETGENERAL ANESTHETICDENTAL ANESTHETICCHEWING INCIDENTCERTAIN FOODSBLOW TO THE JAWBLOW TO THE HEADSUDDEN ONSETOTHER

My problem is made worse by:
YAWNINGSTRESSWALKINGTALKINGSWALLOWINGSPECIFICFOODSSLEEPSINGINGPREGNANCYPHYSICAL ACTIVITYOPENING WIDENO REASONMENSTRUAL PERIODJAW MOVEMENTHEAD MOVEMENTFATIGUEDENTAL VISITSCOUGHINGCHEWINGBENDING OVEROTHER

Sleep Pattern

Do you snore ?
YesNo

Have you been diagnosed with sleep apnea?
YesNo

Do yo wear a CPAP?
YesNo

Have you had a sleep examination in a sleep centre?
YesNo

Do you gasp for breath during the night?
YesNo

Jaw Pain and Function

Please check off the problems that you experience and the side(s) it relates to. Please select left, right or check both boxes if it applies:

Pain on opening
LeftRight

Pain on opening wide (Yawning)
LeftRight

Pain on left movement
LeftRight

Pain on right movement
LeftRight

Pain on close
LeftRight

Pain while clenching
LeftRight

Pain while chewing
LeftRight

Pain at rest
LeftRight

Jaw popping, clicking on opening
LeftRight

Jaw popping, clicking on closing
LeftRight

Jaw previously popped/clicked on opening
LeftRight

Jaw previously popped/clicked on closing
LeftRight

Jaw Grinding, Granting noise
LeftRight

Limited opening of jaw
LeftRight

Jaw sometimes locks closed
LeftRight

Jaw sometimes locks open
LeftRight

Can't move jaw
LeftRight

Jaw goes Left on opening
YesNo

Jaw goes Right on opening
YesNo

Jaw goes ZIGZAGZZ on opening
YesNo

Do neck movements or postural changes increase facial, ear or head pain?
YesNo

Do your job / daily activity involve poor head, neck or back posture?
YesNo

Do you have difficulty finding a comfortable position at night?
YesNo

Any previous examinations / tests for your spine?
YesNo

Previous Treatment

Please indicate other practitioners i.e.: Physicians, Medical Specialists, Chiropractors, Physical Therapists, etc. that you are seeing or have seen for this problem.

Currently being treated?
YesNo

Currently being treated?
YesNo

Currently being treated?
YesNo

Currently being treated?
YesNo

Dental History

Do you have any missing teeth that need replacement?
yesNo

Have you ever been told that you need braces or jaw surgery?
yesNo

Do you have or have you ever had any of the following:
Bite adjustmentsSplint treatmentExtensive crown / bridge workRemoval of wisdom teethGum treatmentOrthodontic treatment

OCCLUSION (HOW YOUR TEETH BITE TOGETHER)

Please check off the problems that apply to you:
My teeth fit together evenly (if not, select from the following)My bite feels off centreMy teeth touch more on the right side than on the leftMy teeth touch more on the left side than on the rightMy back teeth touch more than my front teethMy front teeth touch more than my back teethI feel that my lower jaw has shifted forwardI feel that my lower jaw has shifted backwardI feel that one tooth hits upon closing my mouth sooner than the restother

GRINDING / CLENCHING

I am aware of doing the following:
Day time grinding of teethNight time grinding of teethDay time clenching of teethNight time clenching of teethDay time clenching of jaw musclesNight time clenching of jaw muscles

Medical Information

Please check the following conditions which apply to your medical history.

Allergy
Hay feverEnvironmentalDrugFoodOther

Artificial Implants
Heart pacemakerHeart valveJoint prosthesisOther

Arthritis
GoutOsteoarthritisRheumatoid arthritisOther

Blood
HemophiliaLeukemiaSickle cell anemiaOther

Endrocrine
DiabetesHypoglycemiaParathyroid diseaseThyroid disease

Eye
GlaucomaOther

Gynecological
HysterectomyHormone replacementsMenopausePMSBirth control pillOther

Heart / Circulatory
ArteriosclerosisHeart defectsCoronary artery diseaseHigh blood pressureLow blood pressurePoor circulationOther

Immune
LupusConnective tissue diseaseChronic fatigue syndromeHIVAidsRheumatic feverOther

Urinary
Bladder infectionsBlood in urineKidney diseaseOther

Liver Disease
Cirrhosis of the liverHepatitis AHepatitis BHepatitis COther

Respiratory
AsthmaChronic coldsEmphysemaFrequent coughSinusPost nasal dripShortness of breathTuberculosisOther

Muscle / Bone
Muscular dystrophyFibrositisFibromyalgiaOsteoporosisChronic back painLeg length discrepancyOther

Eye
GlaucomaOther

Nerve
Cerebral palsyEpilepsyNeuralgiaMultiple sclerosisParkinson’s diseaseStrokeOther

Nutritional
Nutrition deficienciesOverweightUnderweightFood sensitive / intolerancesOther

Behavioral
CounselingPsychological carePsychiatric careAnxietyDepressionNervous breakdownPhobiaAlcoholismDrug addictionRelaxation therapyStress managementOther

Skin / Mucosal
EczemaPsoriasisSclerodermaOther

Gastrointestinal
ColitisUlcersCanker soresIrritable bowel syndromeHiatus herniaAnorexiaBulimiaGall bladderOther

Growths
TumorCancerChemotherapyRadiation therapyOther

MEDICATION

All medication currently being taken: (including prescription, homeopathic, supplements & vitamins)

Name of drug Taken for how long Reason for use Result

Medications you have previously taken for this problem:

Name of drug Taken for how long Reason for use Result

RECENT LIFE EVENTS

Marriage
YesNo

Divorce
YesNo

Major Personal Injury / Illness
YesNo

Loss of Family member / Friend
YesNo

Problems at Work
YesNo

Retirement
YesNo

OCCUPATIONAL CONCERNS

My normal day includes:

Frequent use of the telephone
YesNo

Cradling the phone between my ear and shoulder
YesNo

Prolonged use of a computer / screen
YesNo

Prolonged sitting in one position
YesNo

Prolonged driving
YesNo

Poor work posture
YesNo

Repetitive patterns of movements / activity
YesNo

Carrying a heavy briefcase / back-pack
YesNo

Excessive talking / yelling
YesNo

Lifting of heavy objects
YesNo

Holding or turning my head away from centre for prolonged periods of time
YesNo

HABITS / ACTIVITIES (check what applies)
Fingernail bitingCheek chewingJutting jaw forwardClicking jaw habitClenching teethGrinding teethPencil / pen chewingGum chewing Holdingchin in palm of handsScuba divingContact sportsBikingSinging

Playing musical instrument with mouth (specify)

I sleep on my
Left sideI wake up from sleep by painRight sideI use more than one pillowStomachI snoreBackI sleep with my mouth openIn all positionsI wake up my partner

Psychological Screening

Please Rate Your Response to The following questions by selecting the appropriate number.

0 - None of the time

1 - A little of the time

2 - A moderate amount of the time

3 - Quite a bit of the time

4 - All the time

My pain interferes with life in general
01234

I have many changing pains
01234

Some doctors said my pain is imaginary
01234

I secretly think that my pain is helpless
01234

I have pain that get worse with stress or tension
01234

Over the years, I have seen under a lot of stress
01234

Recently, I have seen under a lot of stress
01234

I feel doctors have failed me
01234

I have health problem which haven't Responded to treatment
01234

During My life, I have many painful disorders
01234

I feel Sad or Depressed
01234

I feel Tense or Worried
01234

I feel Anxious or Nervous
01234

I am constantly made miserable by poor health
01234

I sleep poorly
01234

I am easily irritated
01234

I am Often Angry or Frustrated
01234

Dr. Jennifer Silver - Cosmetic Dentistry - Making better SmilesFREE CONSULTATION