MUSCULOSKELETAL SCREENING QUESTIONNAIRE

MUSCULOSKELETAL SCREENING QUESTIONNAIRE - PATIENT

One or more of the following symptoms may be indicative of Musculoskeletal Dysfunction of the head and neck. If you have any of the following symptoms, please indicate by checking the appropriate boxes. (L = Left/ R = Right)

Pain in jaw joints

LeftRight

Pain in ears

LeftRight

Pain around eyes

LeftRight

Pain in lower jaw

LeftRight

Pain in upper jaw

LeftRight

Pain in neck

LeftRight

Pain in shoulder

LeftRight

Pain in forehead

LeftRight

Pain in temples

LeftRight

Pain in facial muscles

LeftRight

Grating sound in joint

LeftRight

Subjective hearing loss

LeftRight

a. Clicking, snapping, or popping sound in joint

LeftRight

b. if yes, is it:

ClickingSnappingPopping

Dizziness (vertigo)

LeftRight

Upset stomach (nausea)

LeftRight

Ringing sound in ears

LeftRight

Headaches

LeftRight

Fullness, pressure blockage in ear

LeftRight

Pain in tongue

LeftRight

a. Partial inability to open mouth

LeftRight

b. If yes, is it:

constantsporadic

Difficulty chewing

YesNo

Difficulty swallowing

YesNo

Loud snoring

YesNo

Constantly tired

YesNo

Mouth breathing at night

YesNo

a. Awaken with dry mouth

YesNo

b. If yes, does it occur:

FrequentlyRarelyNever

What are the chief complaints? List from most to least important:

a.

b.

c.

Other symptoms

Do symptoms affect one or both joints?

LeftRightBoth

If both joints, indicate which joint seems most affected:

LeftRight

How many years, months, weeks, or days have you been bothered by this problem?

Years

Months

Weeks

Days

Have you had any injury to the jaw or face?

YesNo

Do you have arthritis?

YesNo

Have you ever had cervical traction?

YesNo

Have you ever worn a neck brace?

YesNo

Have you had any other treatment for this problem:

YesNo

If yes, please explain: (medicine, exercise, dental appliances such as a splint or night guard)