Child TMJ Questionnaire

Child TMJ Questionnaire

In order for us to properly diagnose and treat our patients, we must have accurate background and health information on which to base our decisions. Please provide the information requested below:
Today's Date:

MonthDayYear
Date
Patient's Name*

First NameLast Name
Sex*

MaleFemale
Date of Birth*

MonthDayYear
Date
Age:*
School:*
Grade:*
Parent or Gardian's Drivers License Number:*
Parent or Guardian Email Address*
example@example.com
Phone:*
Please enter a valid phone number.
Patient Lives With:*

MotherFatherOther
If "Other" please specify:
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Patient's Dentist:*
Patient's Physician:*
Referred By:*
Father's Name:

First NameLast Name
Father's mobile phone number:
Please enter a valid phone number.
Father's Address (if different from patient's address):

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Father's SS#:
Father's Date of Birth:

MonthDayYear
Date
Father's Employer:
Father's Work Phone Number:
Please enter a valid phone number.
Name of Father's Dental Insurance Company:
Father's Dental Insurance Company Phone Number:
Please enter a valid phone number.
Father's Dental Insurance ID:
Father's Dental Insurance Group Number:
Father's Dental Insurance Address PO Box:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mother's Name:

First NameLast Name
Mother's mobile phone number:
Please enter a valid phone number.
Mother's Address (if different from patient's address):

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mother's SS#:
Mother's Date of Birth:

MonthDayYear
Date
Mother's Employer:
Mother's Work Phone Number:
Please enter a valid phone number.
Name of Dental Insurance Company:
Insurance Company Phone Number:
Please enter a valid phone number.
Insurance ID:
Group Number:
Insurance Address PO Box:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Person Financially Responsible for the Account:*
Is the Patient Covered By Insurance for Orthodontic Treatment?*

YesNo
Is the Patient Covered By Insurance for TMJ Treatment?*

YesNo
Name of Medical Insurance Company:*
Medical Insurance Company Phone Number:*
Please enter a valid phone number.
Medical Insurance ID:*
Medical Insurance Group Number:*
Medical Insurance Address PO Box:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Who referred you to this office for TMJ treatment?

Family DentistFamily PhysicianSomeone Else
Please provide contact information of who referred you to our office
INSTRUCTIONS:

The first part of your health questionnaire is designed to help us focus upon your specific concerns. The second part of the questionnaire will allow you to provide any explanations necessary to enhance our overall understanding. Although some questions may seem somewhat “strange” or not applicable to you there is a specific reason behind each question asked. The accuracy and completeness of your answers directly affect the diagnostic decisions and treatment recommendations made on your behalf. Your confidentiality will be respected. Please give this exercise your “best effort.”
HEAD NECK, AND FACE SYMPTOMS:

Please select the appropriate response indicating whether or not you currently have (current condition), previously had (previous condition), or never had the following conditions or symptoms and identify a “right side” or “left side” location where appropriate.
Painful or sore teeth*

Current conditionPrevious conditionNever had
Teeth Sensitive to hot or cold*

Current conditionPrevious conditionNever had
Gum disease or bleeding gums*

Current conditionPrevious conditionNever had
Oral surgery*

Current conditionPrevious conditionNever had
Wisdom teeth removed*

Current conditionPrevious conditionNever had
Caps or crowns on teeth*

Current conditionPrevious conditionNever had
Teeth ground by dentist*

Current conditionPrevious conditionNever had
Chew gum*

Current conditionPrevious conditionNever had
Have you ever had orthodontic treatment*

Current conditionPrevious conditionNever had
Have you ever had periodontal disease (pyorrhea)?*

Current conditionPrevious conditionNever had
Have you ever been treated for a bad bite?*

Current conditionPrevious conditionNever had
Do you have missing back teeth and no replacement?*

Current conditionPrevious conditionNever had
Do you feel that your bite is closed?*

Current conditionPrevious conditionNever had
Do you feel that there is enough room for your tongue?*

Current conditionPrevious conditionNever had
Are any of your teeth worn badly?*

Current conditionPrevious conditionNever had
Are any of your teeth very loose?*

Current conditionPrevious conditionNever had
Have you had teeth extracted within the last 3 years?*

Current conditionPrevious conditionNever had
Accident to teeth?*

Current conditionPrevious conditionNever had
Accident to jaws?*

Current conditionPrevious conditionNever had
Accident to face?*

Current conditionPrevious conditionNever had
PAIN
Do you have tension headaches?*

YesNo
Are there time when you notice that this problem is less or gone completely?*

YesNo
Do your teeth hurt from clenching or chewing?*

YesNo
Does the pain or discomfort disturb your sleep?*

YesNo
Is there constant or recurring pain?*

NoYes or left sideYes on right sideYes on both sides
Would you describe the pain as dull, aching sensation?*

NoYes or left sideYes on right sideYes on both sides
Would you describe the pain as a stabbing, sharp, or severe sensation?*

NoYes or left sideYes on right sideYes on both sides
Does your jaw ache when you chew?*

YesNo
Does your jaw hurt when you open wide or take a big bite?*

YesNo
Do you have ear pain?*

NoYes or left sideYes on right sideYes on both sides
Have you ever had chronic shoulder or back pain?*

NoYes or left sideYes on right sideYes on both sides
Do you have pain in the teeth on arising?*

NoYes or left sideYes on right sideYes on both sides
Do you have headaches in the left or right temple?*

NoYes or left sideYes on right sideYes on both sides
Do you have headaches in the back of your head?*

YesNo
Do you have generalized facial pain?*

YesNo
Is the degree of pain the same in the morning as the evening*

NoYes or left sideYes on right sideYes on both sides
Do you have a chronic stiff neck?*

YesNo
Do you have neckaches or neck pain?*

YesNo
Does it now hurt to open wide?*

YesNo
Have you ever been operated on for pain?*

YesNo
Did the operation bring you relief from pain?*

YesNo
Did any of the injections bring relief from pain?*

YesNo
How often do you take medicine for relief of pain?

neververy seldomfairly oftenoftenregularly
TMJ SYMPTOMS
Can you open your mouth all the way?*

YesNo
Does your mouth goes to one side when fully opened?*

YesNo
Do you have numbness of the shoulder, arms, hands, or fingers?*

YesNo
Do you have shoulder pain?*

YesNo
Has your jaw ever locked so you were unable to open or close it?*

YesNo
Does your jaw ever make any noise?*

YesNo
Have you ever been treated for problems of your jaw joint or facial muscle spasms?*

YesNo
Do you ever awaken with awareness of your teeth or jaws?*

YesNo
Are you aware of clenching your teeth during the day?*

YesNo
Do you have difficulty in opening your mouth widely?*

YesNo
Do you have difficulty swallowing?*

YesNo
Have you ever had pain in your jaw joint?*

YesNo
Do you ever hear grating sounds from your jaw joint?*

YesNo
Do you ever hear or feel a clicking or popping from your jaw joint?*

YesNo
Does your jaw make clicking or popping sounds when you chew?*

YesNo
Does your jaw feel tired after a big meal?*

YesNo
Has anyone else ever heard you grinding your teeth in your sleep?*

YesNo
Has anyone else ever heard you grinding your teeth during the daytime?*

YesNo
Are you aware that you clench your teeth during the night?*

YesNo
Does it hurt now to open wide?*

YesNo
Does it ever hurt to open wide?*

YesNo
EARS
Do you have itchiness or stuffiness in your ears?*

YesNo
Do you have ringing, hissing, or buzzing sounds in your ears?*

YesNo
Do you have grating noises (like sand particles) in your ears?*

YesNo
Do you get earaches or ear pain?*

YesNo
Have you experienced hearing loss?*

YesNo
Do you have throbbing or whooshing sounds in your ears?*

YesNo
BREATHING
Do you have alergies?*

YesNo
Do you have sinus problems?*

YesNo
Is your nose ever stuffed when you don't have a cold?*

YesNo
Does your nose ever run when you don't have a cold?*

YesNo
Do you snore?*

YesNo
Are you a mouth breather?*

YesNo
POSTURE
Do you have abnormal curvature of the spine?*

YesNo
Do you experience backaches?*

YesNo
Do you have unequal leg length?*

YesNo
Are you able to sit still for a prolonged period of time?*

YesNo
Do you cradle the phone between your head and shoulders?*

YesNo
Does your work involve typing/word processing?*

YesNo
Do you wear high heels?*

SelomOccasionallyFrequentlyNever
EYES
Do you have pain in, around, or behind your eyes?*

YesNo
Do you experience eyelid tics or twitches?*

YesNo
Do your eyes blink or water most of the time?*

YesNo
Does your eyesight ever blur?*

YesNo
EQUILIBRIUM
Do you ever experience dizziness or lightheadedness?*

YesNo
Do you often feel nauseous (like vomiting) ?*

YesNo
TRAUMA
Have you have ever had an accident or trauma to the head?*

YesNo
Have you have ever had an accident or trauma to the face?*

YesNo
Have you have ever had an accident or trauma to the jaw?*

YesNo
Have you have ever had an accident or trauma to the neck?*

YesNo
Have you ever had whiplash or a neck injury?*

YesNo
Have you ever had cervical traction or a neck collar?*

YesNo
Have you ever received a severe blow to the side of the had or jaw?*

YesNo
Was there ever a strain or stretching of the jaw such as yawning during a dental procedure, while chewing, or opening the mouth wide?*

YesNo
Have you ever had a broken jaw?*

YesNo
Have you experienced a fall within the last 3 years?*

YesNo
LIFESTYLE
Do you usually eat breakfast?*

YesNo
Do you bite your nails, tongue, or lips?*

YesNo
Do you have any mood swings affecting drugs or stimulants?*

YesNo
Do you exercise regularly?*

YesNo
Do you work more than 40 hours per week?*

YesNo
MEDICAL HISTORY:

Please select the appropriate response indicating whether or not you currently have (current condition), previously had (previous condition), or never had the following conditions or symptoms.
Arteriosclerosis*

Current conditionPrevious conditionNever had
Rheumatoid arthritis*

Current conditionPrevious conditionNever had
Swolen, stiff, or painful joints*

Current conditionPrevious conditionNever had
Osteoarthritis (neck, joints, etc.)*

Current conditionPrevious conditionNever had
Heart trouble*

Current conditionPrevious conditionNever had
Heart murmur*

Current conditionPrevious conditionNever had
Pains or tightness in chest*

Current conditionPrevious conditionNever had
Low blood pressure (hypotension)*

Current conditionPrevious conditionNever had
High blood pressure (hypertension)*

Current conditionPrevious conditionNever had
Fainting spells or feeling faint?*

Current conditionPrevious conditionNever had
Feel exhausted or fatigued most of the time*

Current conditionPrevious conditionNever had
Swollen ankles or feet*

Current conditionPrevious conditionNever had
Hands get cold*

Current conditionPrevious conditionNever had
Bruise easily*

Current conditionPrevious conditionNever had
Slow healing sores*

Current conditionPrevious conditionNever had
Muscle soreness or stiffness*

Current conditionPrevious conditionNever had
Had tremors*

Current conditionPrevious conditionNever had
Diabetes*

Current conditionPrevious conditionNever had
More thirsty than usual lately*

Current conditionPrevious conditionNever had
High or low blood sugar*

Current conditionPrevious conditionNever had
Sugar in urine*

Current conditionPrevious conditionNever had
Blood in urine*

Current conditionPrevious conditionNever had
Shortness of breath*

Current conditionPrevious conditionNever had
Use extra pillows to breathing at night*

Current conditionPrevious conditionNever had
Hard to concentrate or remember*

Current conditionPrevious conditionNever had
Difficulty falling asleep or staying asleep*

Current conditionPrevious conditionNever had
Frequently irritable*

Current conditionPrevious conditionNever had
Endocrine or hormone problems*

Current conditionPrevious conditionNever had
Cancer*

Current conditionPrevious conditionNever had
Any history of substance use or abuse*

Current conditionPrevious conditionNever had
Numbness of hands or arms*

Current conditionPrevious conditionNever had
Asthma*

Current conditionPrevious conditionNever had
AIDS*

Current conditionPrevious conditionNever had
Autoimmune disorder*

Current conditionPrevious conditionNever had
Hepatitis*

Current conditionPrevious conditionNever had
MEDICINES:

Please select the appropriate response indicating whether you are sensitive or alergic to or are now taking any of the following medications.
Heart pills (Digitalis, etc.)

Now takingSensitive or Allergic to
Nerve pills

Now takingSensitive or Allergic to
Diet pills -diuretics

Now takingSensitive or Allergic to
Pain pills (Demerol, Codeine, etc.)

Now takingSensitive or Allergic to
Vitamins

Now takingSensitive or Allergic to
Birth Control pills

Now takingSensitive or Allergic to
Sleeping pills

Now takingSensitive or Allergic to
Muscle relaxants

Now takingSensitive or Allergic to
Insulin

Now takingSensitive or Allergic to
If you are now taking or are sensitive or allergic to any other medications, please list them here
FOOD ALLERGIES:

Please select the appropriate response indicating whether you have an allergic response to any of the following foods:
Dairy products

YesNo
Wheat, cereals

YesNo
Dyes in food

YesNo
If you have any allergic response to any other foods, please list them here
PRACTITIONERS:

Since your pain began, which of the following people have you seen for pain relief?
Acupuncturists

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Allergist

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Anesthesiologist

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Cardiologist (heart)

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Chiropractor

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Clergyman

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Dentist

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Dermatologist (skin)

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Dietician

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Ear, nose and throat specialist

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Endocrinologist

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Faith healer

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Family physician

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Gynecologists/obstetrician

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Hypnotist

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Internist

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Naturopath

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Neurologist

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Neurosurgeon

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Nutritionist

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Ophthalmologist (eyes)

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Optometrist

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Orthopedist (bones, joints)

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Orthodontist

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Physical therapist

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Plastic surgeon

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Proctologist

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Psychiatrist

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Psychologist

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Radiologist

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Rheumatologist

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Surgeon

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If you have seen any other practitioners since your pain began, please list them here
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