Medical History Form

TMJ SYNDROME AND MYOFASCIAL PAIN HEALTH HISTORY QUESTIONNAIRE
Patient Name
Date of Birth

Month Day Year
Date
Age
Sex
SSN/SSIN
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
CHIEF COMPLAINT(S)
1) Describe what you think the problem is:
2) What do you think caused this problem?
3) Describe in order (first to last) what you expect from the treatment
MEDICAL AND DENTAL HISTORY
1) Are you presently under the care of a physician or have you been in the past year?

Yes No
Physician’s name:
Conditions Treated
TREATMENT
1) Name of Medications you are currently taking
2) How would you describe your overall physical health?(select one)

Poor Average Excellent
3) How would you describe your dental health?(select one)

Poor Average Excellent
Dentist Name:
Date of Last Appointment

Month Day Year
Date
4) Have you had any major dental treatment in the last two years? (select one)

Yes No
If yes, please mark procedure(s):

Orthodontics Periodontics Oral Surgery Restorative
Date(s) of Third Molar (wisdom tooth) extraction(s):
HISTORY OF INJURY AND TRAUMA
1) Is there any childhood history offalls, accidents of injury to the face of head?

Yes No
Describe:
2) Is there any recent history of trauma to the head or face? (Auto accident, sports injury, facial impact)

Yes No
Describe:
3) Is there any activity which holds the head or jaw in an imbalanced position? (Phone, Swimming, Instrument)

Yes No
Describe:
FACIAL PAIN PAST TREATMENT
1) Have you ever been examined for a TMD problem before?

Yes No
If yes, by whom? When?
2) What was the nature of the problem (Pain, noise, limitation of movement)
3) What was the duration of the problem? Months? Years?
Is this a new problem?

Yes No
4) Is this problem getting better, worse or staying the same?
5) Have you ever had physical therapy for TMD?

Yes No
If yes, by whom? When?
6) Have you ever received treatment for jaw problems?

Yes No
If yes, by whom? When?
What was the treatment? (Please mark Below)

Bite Splint Medication Physical Therapy Occlusal Adjustment Orthodontics Counseling Surgery
Please Explain
7) Have you ever had injections for your TMD with musclerelaxants (Botox, Flexeril) cortisone or anti-inflammatories?

Yes No
If Yes, were they effective

Yes No
8) How many dental appliances have you worn?
9) Were these appliances effective?

Yes No
10) Is there any additional information that can help us in this area
CURRENT STRESS FACTORS (PLEASE MARK EACH FACTOR THAT APPLIES TO YOU)

Death of a Spouse Major Illness or Injury Major Health Change in Family Business Adjustment Divorce Pending Marriage Financial Problems Pregnancy Career Change Fired from Work Marital Reconciliation Debt Death of a Family Member New Person Joins Family Marital Separation
CURRENT AND PREVIOUS HABITS (PLEASE MARK YOUR ANSWER TO EACH QUESTION)
1) Do you clench your teeth together under stress?

Yes No Don't Know
2) Do you grind/clench your teeth at night?

Yes No Don't Know
3) Do you sleep with an unusual head position

Yes No Don't Know
4) Are you aware of any habits or activities that may aggravate this condition

Yes No Don't Know
Describe
CURRENT SYMPTOMS (PLEASE MARK EACH SYMPTOM THAT APPLIES)
A. HEAD PAIN, HEADACHES, FACIAL PAIN
Forehead

L R
Temples

L R
Migraine Type Headaches Cluster Headaches Maxillary Sinus Headaches (under the eyes) Occipital Headaches (back of the head with or without shooting pain) Hair and/or Scalp Painful to Touch
B. EYEPAIN / EAR ORBITAL PROBLEMS

Eye Pain - Above, Below or Behind Bloodshot Eyes Blurring of Vision Bulging Appearance Pressure Behind the Eyes Watering of the Eyes Drooping of the Eyelids
C. MOUTH, FACE, CHEEK& CHIN PROBLEMS

Discomfort Limited Opening Inability to Open Smoothly
D. TEETH & GUM PROBLEMS

Clenching, Grinding at Night Looseness and/or Soreness of Back Teeth Tooth Pain
E. JAW & JAW JOINT (TMD) PROBLEMS

Clicking, Popping Jaw Joints Jaw Locking Opened or Closed Pain in Cheek Muscles Uncontrollable Jaw/Tongue Movements
F. PAIN, EAR PROBLEMS, POSTURAL IMBALANCES

Hissing, Buzzing, or Ringing Sounds Ear Pain without Infection Clogged, Stuffy, Itchy Ears Balance Problems – “Vertigo” Diminished Hearing
G. NECK & SHOULDER PAIN

Arm and Finger Tingling, Numbness, Pain Reduced mobility and range of motion Stiffness Neck Pain Tired, Sore Neck Muscle Back Pain, Upper and Lower Shoulder Aches
H. THROAT PROBLEMS

Swallowing Difficulties Tightness of Throat Sore Throat Voice Fluctuations
I. OTHER PAIN
CURRENT MEDICATIONS / APPLIANCES / TREATMENTS BEING USED

1) Degree of current TMD pain:

	1	2	3	4	5	6	7	8	9	10

1 is NO PAIN, 10 is SEVERE PAIN

2) Frequency of TMD pain:

Daily Weekly Monthly After Eating
Is the pain constant, continuous, or intermittent
How long does it last
What is the quality of the pain? Sharp, dull, burning, aching, electrical etc
What makes it worse?
What makes it better?
How often does the pain occur?
Does the pain occur on it's own or do you need to trigger with function, touching etc?
If you were to place Q-tip in your left ear and move forward, does that trigger pain?
Can the pain be triggered by touching the skin with a light brush stroke with a Q-tip or pressing on an area with a Q-tip
3) Are you taking medications for the TMD problems

Yes No
If so, what type?
How long?
Who prescribed the medication
4) Are the medications that you are taking effective?

Yes No
Conditional?
5) Are you aware of anything that makes your pain worse?

Yes No
If yes, what?
6) Does your jaw make noise?

Yes No
If so, when and how?
Right

Clicking/Popping Grinding
Left

Clicking/Popping Grinding
7) Does your jaw lock open?

Yes No
If yes, when did this first occur?
How often
8) Has your jaw ever locked closed or partly closed?

Yes No
If yes, when did this first occur?
How often
9) Have any dental appliances been prescribed?

Yes No
If yes, by whom?
When?
Describe
When do you wear your dental appliances?
Signature - Use your mouse to sign your signature *

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TMJ SYNDROME AND MYOFASCIAL PAIN HEALTH HISTORY QUESTIONNAIRE

CHIEF COMPLAINT(S)

MEDICAL AND DENTAL HISTORY

TREATMENT

HISTORY OF INJURY AND TRAUMA

FACIAL PAIN PAST TREATMENT

CURRENT AND PREVIOUS HABITS (PLEASE MARK YOUR ANSWER TO EACH QUESTION)

CURRENT SYMPTOMS (PLEASE MARK EACH SYMPTOM THAT APPLIES)

A. HEAD PAIN, HEADACHES, FACIAL PAIN

CURRENT MEDICATIONS / APPLIANCES / TREATMENTS BEING USED