Intake Questionnaire

Language

English (UK)
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French (France)

Introduction
Dear Sir, Mme,

You can change the language of this form in the top corner of this page.

The following questionnaires will help you to understand your orofacial pain or symptoms better. After completion you will be able to download a report that you can share with your physician or anyone who is helping you with your condition.

All data is kept strictly confidential. By completing this questionnaire you agree with our terms and conditions and privacy policy.

The questionnaires are dynamic. The time to complete the questionnaire may vary depending on your answers. Maximum time will be 15 minutes.

We sincerely hope this will help you and your doctors in making better health decisions. Thank you for your time and using our tool.

General information
What is your name?*

First nameLast name
What is your date of birth?*

DayMonthYear
Date
Current date

DayMonthYear
Date
Age
Gender*

MaleFemaleOther
Where do you live?*
What is your email address?*
yourname@organisation.com
What is the highest degree or level of school you have completed? If currently enrolled, highest degree received.*

No schooling completedNursery school to 8th gradeSome high school, no diplomaHigh school graduate, diploma or the equivalentSome college credit, no degreeTrade/technical/vocational trainingAssociate degreeBachelor's degreeMaster's degreeProfessional degreeDoctorate degree
What is your current professional status?*

EmployedSelf-employed or contractorUnemployedUnemployed, retiredUnemployed due to condition other than the one for which I am now seeking helpUnemployed because of the condition for which I am seeking help NOW
Since when have you been unable to work?*

DagMaandJaar
Date
Give a short job description (current or most recent).
What is your marital status?*

Single, never marriedSeperatedMarried or domestic partnershipDivorcedWidowed
Current history
When did your current symptoms start? Be as precise as possible*

DagMaandJaar
Where are your symptoms located?*

Always on the left sideAlways on the right sideOn both sidesMy symptoms jump from one side to the other
What is your most worrisome or troublesome symptom?*

PainReduced / numb feelingBoth (decreased sensation and pain)
Did you experience unusual weight loss in the past month?*

YesNo
Did you experience night sweats?*

YesNo
Have you noticed a sudden decrease in your vision?*

YesNo
Do you have a fever?*

YesNo
Are you or might you be pregnant?*

YesNo
Red flags
Over the past two weeks, how often have you been bothered by thoughts that you would be better off dead, or thoughts of hurting yourself in some way?*

Not at allSeveral daysMore than half the daysNearly every day
How did your symptoms start?*

By itselfA traumatic event (surgery, cosmetic procedure, dental procedure, injury to the face or mouth)A significant life event (accident, bereavement, other)
Did you symptoms start immediately after the event?*

YesNo
What was carried out?*

Local anaesthetic injectionRemoval of wisdom teethNon-wisdom tooth extractionJaw osteotomy / oral surgeryPlacement of implantsRoot canal treatmentFacial or jaw fracture or other facial traumaOther
Describe the locations of all your different symptoms (e.g. numbness) or pains. Be as precise as possible. If your pain radiates, please explain where your pain radiates to. An example is given below.*
What are your main concerns regarding your condition?*

Understanding the causeSymptom reliefOther
What are your expectations, wishes or hopes regarding further investigations and treatments?*
Was there any severe pain or electric shock during the procedure?*

YesNo
With whom did the treatment take place? Please name the practitioner and location.*
Since your complaints began, what has been the evolution? Please indicate:*

No changeSlight improvementClear improvementSlight deterioration or increaseSignificant deterioration or increase
Have you already been diagnosed with one of the following conditions? Please indicate all that apply.

Doctors fail to diagnose meMigraine / tension-type headacheTemporomandibular joint dysfunction / Myofascial orofacial painBurning mouth syndromeAtypical facial pain / Persistent idiopathic facial painNeuropathic pain / Post-traumatic trigeminal neuropathic painAtypical odontalgia / Phantom tooth pain / Persistent dento-alveolar painTrigeminal neuralgiaTrigeminal autonomic cephalalgia / Cluster headache / SUNCT / SUNA / Hemicrania continua / Paroxysmal hemicraniaGlossopharyngeal neuralgiaEar ache or pain caused by ear problemsFibromyalgiaChronic fatigue syndromeChronic lower back pain / Chronic neck pain / Cervicalgia / Failed back surgery syndromeChronic widespread painOther pain condition
Indicate the locations of all your different symptoms (e.g. numbness) or pains by drawing on the illustration below. If your pain radiates, please use an arrow to indicate where your pain radiates to. *
Pain history
If you have pain NOW, how bad is it on a scale of 0 to 100. "0" means no pain, "100" means the worst pain you can imagine.*
How bad is the pain AVERAGE on a scale from 0 to 100. "0" means no pain, "100" means the worst pain you can imagine.*
How bad is the pain MAXIMUM on a scale from 0 to 100. "0" means no pain, "100" means the worst pain you can imagine.*
Indicate the course of your pain*

persistent pain with fluctuationspain attacks WITH pain between the attackspain attacks WITHOUT pain between the attacks
Does the pain wake you up?*

YesNo
How long does your pain last? If you have continuous pain with attacks, please indicate how long an attack lasts.*

Seconds0-30 minutes30 minutes - 3 hours3 hours tot 3 days3 to 7 daysMore than 7 days
Indicate the words that describe your pain.*

Burning sensationPainful cold sensationElectric shocksTinglingPrickingNumbnessItchingFlickeringQuiveringPulsingThrobbingBeatingPoundingJumpingFlashingShootingBoringDrillingStabbingLancinatingSharpCuttingLaceratingPinchingPressingCrampingGnawingCrushingTuggingPullingWrenchingHotBurningScaldingSearingTinglingSmartingStingingDullSoreHurtingAchingHeavyTenderTautRaspingSplittingTiringExhaustingSickeningSuffocatingFearfulFrightfulTerrifyingPunishingGruellingCruelViciousKillingWretchedBlindingAnnoyingTroublesomeMiserableIntenseUnbearableSpreadingRadiatingPenetratingPiercingTightNumbDrawingSqueezingTearingFreezingNaggingNauseatingAgonizingDreadfulTorturingPullingStretchingAnts crawlingOther
Can the pain be provoked?*

YesNo
It can be provoked by

TouchBrushing teethDrinkingWashing the faceSmokingTalkingShavingKissingLaughingApplying makeupSingingPlaying a wind instrumentCold breezeWarm breezeDrinking alcoholSmokingCafeine / CoffeeEstrogen depletion / menstrual cycle / postmenopausalOther

Do these signs happen at the same time when the pain is at it worst?*

	Yes	No
I have a watery eye on the side of the pain
I have a red eye on the side of the pain
Do you have nasal congestion on the side of the pain?
Do you have a red or flushed skin where it is hurting?

Autonomic score
Autonomic score qualitative
Does your pain radiate?*

YesNo
Where does your pain radiate to? Describe this as accurately as possible.
Are there things that relieve the pain? If so, what?

AntibioticsParacetamol / acetaminophenAnti-inflammatory drugs (NSAIDS, ibuprofen, diclofenac,...)SleepHolidayRestDrinking alcoholSmokingApplying pressure to the areaApplying cold pack to the areaApplying hot pack to the areaOther
Do you have other pains?*

Headache (migraine, tension type headache,...)Other pains in the body (back pain, neck pain, joint pain, IBS, vulvodynia,...)I don't have pain elsewhere in the body
I have pain all over my body*

YesNo
Is your pain accompanied by a continuous and very unpleasant general fatigue?*

YesNo
Does your pain feels like burns, electric shocks or cramps*

YesNo
Is your pain accompanied by other unusual sensations throughout your body, such as pins and needles, tingling or numbness?*

YesNo
Is your pain accompanied by other health problems such as digestive problems, urinary problems, headaches or restless legs?*

YesNo
Has your pain a signiﬁcant impact on your life, particularly on your sleep and your ability to concentrate, making you feel slower generally*

YesNo
Have you experienced recurrent headaches in the past 3 months that typically start with a throbbing or pulsating pain on one side of your head?*

YesNo
Do these headaches tend to worsen with physical activity, such as walking, climbing stairs, or routine daily tasks?*

YesNo
During these headache episodes, have you often felt nauseated or experienced vomiting, especially if left untreated?*

YesNo
Migraine score
Migraine score qualitative
FiRST score
Fibromyalgia score
Fibromyalgia score qualitative

We are interested in the types of thoughts and feeling that you have when you are in pain. Listed below are thirteen statements describing different thoughts and feelings that may be associated with pain. Using the scale, please indicate the degree to which you have these thoughts and feelings when you are experiencing pain.*

	Not at all	To a slight degree	To a moderate degree	To a great degree	All the time
1. I worry all the time about whether the pain will end
2. I feel I can’t go on
3. It’s terrible and I think it’s never going to get any better
4. It’s awful and I feel that it overwhelms me
5. I feel I can’t stand it anymore
6. I become afraid that the pain will get worse
7. I keep thinking of other painful events
8. I anxiously want the pain to go away
9. I can’t seem to keep it out of my mind
10. I keep thinking about how much it hurts
11. I keep thinking about how badly I want the pain to stop
12. There’s nothing I can do to reduce the intensity of the pain
13. I wonder whether something serious may happen

PCS Total
PCS score qualitative
PCS Total on 100
PCS Rumination
PCS Magnification
PCS short
PCS Helplessness
Medication use
Did you try any of the medications in the PAST for your symptoms? Please indicate.

Vitamin BCorticosteroidsParacetamol / acetaminophenIbuprofenTramadolMorphineCarbamazepine (Tegretol)Pregabalin (Lyrica)Gabapentin (Neurontin)OxcarbazepineAmitriptylineNortriptylineBisoprolol (Isoten)Triptans (sumatriptan, zolmitriptan)DuloxetineVenlafaxineLamotrigineTipentadolCanabinoids or CBD oilOther

Please specify the highest daily dosage of any medication you have previously taken, along with the reason for discontinuing its use.

	The maximum daily dose I toke was	The reason I stopped was
Vitamin B
Corticosteroids
Paracetamol / acetaminophen
Ibuprofen
Tramadol
Morphine
Carbamazepine (Tegretol)
Pregabalin (Lyrica)
Gabapentin (Neurontin)
Oxcarbazepine
Amitriptyline
Nortriptyline
Bisoprolol (Isoten)
Triptans (sumatriptan, zolmitriptan)
Duloxetine
Venlafaxine
Lamotrigine
Tipentadol
Canabinoids or CBD oil
Other

Are you NOW taking any of the medications for your symptoms? Please indicate.

Vitamin BCorticosteroidsParacetamol / acetaminophenIbuprofenTramadolMorphineCarbamazepine (Tegretol)Pregabalin (Lyrica)Gabapentin (Neurontin)OxcarbazepineAmitriptylineNortriptylineBisoprolol (Isoten)Triptans (sumatriptan, zolmitriptan)DuloxetineVenlafaxineLamotrigineTipentadolCanabinoids or CBD oilOther
Have you had any other treatments for your problem? If so, please indicate them below. You can also add other treatments yourself.

PhysiotherapyPsychological interventions (cognitive behavioral therapy, acceptance and commitment therapy, mindfulness,...)Dental treatmentsInjectionsAcupunctureHypnosisNeurostimulation / pulsed radio frequencyNeuroablation (Gamma knife, thermocoagulation, radiofrequent ablation, neurotomy, neurolysis)Surgical nerve reconstructionExploratory surgeryOther

Functionality

For each of the items below, please indicate the level of restriction during the past month. If the activity was completely avoided because it was too difficult, please indicate "10". "0" means that you had no restrictions in this activity. If you avoid an activity for reasons other than pain or difficulty, leave the item blank.*

	0	1	2	3	4	5	6	7	8	9	10
Overall activity
Mood
Relationship with other people
Joy in life
Chewing
Drinking
Swallow
Yawning
Speaking
Laughing
Kissing
Sleeping

DAL impact score
DAL impact score qualitative
Impact - overall activity
Impact - Mood
Impact - Relationships
Impact - Joy in life
Impact - Chewing
Impact - Drinking
Impact - Swallowing
Impact - Yawning
Impact - Speaking
Impact - Laughing
Impact - Kissing
Impact - Sleeping

Quality of Life

Indicate below what best suits your health TODAY.
Mobility*

I have no problems in walking aboutI have slight problems in walking aboutI have moderate problems in walking aboutI have severe problems in walking aboutI am unable to walk about
Self-care*

I have no problems washing or dressing myselfI have slight problems washing or dressing myselfI have moderate problems washing or dressing myselfI have severe problems washing or dressing myselfI am unable to wash or dress myself
Usual activities (e.g. work, study, housework, family or leisure activities)*

I have no problems doing my usual activitiesI have slight problems doing my usual activitiesI have moderate problems doing my usual activitiesI have severe problems doing my usual activitiesI am unable to do my usual activities
Pain / discomfort*

I have no pain or discomfortI have slight pain or discomfortI have moderate pain or discomfortI have severe pain or discomfortI have extreme pain or discomfort
Anxiety / depression*

I am not anxious or depressedI am slightly anxious or depressedI am moderately anxious or depressedI am severely anxious or depressedI am extremely anxious or depressed
We would like to know how good or bad your health is TODAY. This scale is numbered from 0 to 100. One hundred means the best health you can imagine. Zero means the worst health you can imagine. Please mark on the scale to indicate how your health is TODAY.*
QoL impact score
QoL score qualitative score

Over the last two weeks, how often have you been bothered by any of the following problems?*

	Not at all	Several days	More than half the days	Nearly every day
1. Feeling nervous, anxious or on edge
2. Not being able to stop or control worrying
3. Little interest or pleasure in doing things
4. Feeling down, depressed, or hopeless

PHQ4 total score
PHQ4 anxiety score
PHQ4 depression score
Anxiety - Depression score
Anxiety - Depression score qualitative

Over the last 2 weeks, how often have you been bothered by any of the following problems? Indicate your answer*

	Not at all	Several days	More than half the days	Nearly every day
1. Little interest or pleasure in doing things
2. Feeling down, depressed, or hopeless
3. Trouble falling or staying asleep, or sleeping too much
4. Feeling tired or having little energy
5. Poor appetite or overeating
6. Feeling bad about yourself — or that you are a failure or have let yourself or your family down
7. Trouble concentrating on things, such as reading the newspaper or watching television
8. Moving or speaking so slowly that other people could have noticed. Or the opposite - being so fidgety or restless that you have been moving around a lot more than usual
9. Thoughts that you would be better off dead or of hurting yourself in some way

If you ticked any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?

Not difficult at allSomewhat difficultVery difficultExtremely difficult
PHQ9 total score

Over the last 2 weeks, how often have you been bothered by the following problems?*

	Not at all	Several days	More than half the days	Nearly every day
1. Feeling nervous, anxious or on edge
2. Not being able to stop or control worrying
3. Worrying too much about different things
4. Having trouble relaxing
5. Being so restless that it is hard to sit still
6. Becoming easily annoyed or irritable
7. Feeling afraid, as if something awful might happen

GAD7 total score

Have you experienced prior abuse and/or neglect in your life? Or was your pain related to trauma? (dental trauma,...)*

YesNo

Below is a list of difficulties people sometimes have after stressful life events. Please read each item, and then indicate how distressing each difficulty has been for you DURING THE PAST SEVEN DAYS with respect to your orofacial pain or discomfort. How much have you been distressed or bothered by these difficulties?*

	Not at all	a little bit	Moderately	Quite a bit	Extremely
1. Any reminder brought back feelings about it
2. I had trouble staying asleep
3. Other things kept making me think about it
4. I felt irritable and angry
5. I avoided letting myself get upset when I thought about it or was reminded of it
6. I thought about it when I didn't mean to
7. I felt as if it hadn't happened or wasn't real
8. I stayed away from reminders of it
9. Pictures about it popped into my mind
10. I was jumpy and easily startled
11. I tried not to think about it
12. I was aware that I still had a lot of feelings about itm but I didn't deal with them
13. My feelings about it were kind of numb
14. I found myself acting or feeling lik ei was back at that time
15. I had trouble falling asleep
16. I had waves of strong feelings about it
17. I tried to remove it from my memory
18. I had trouble concentrating
19. Reminders of it caused me to have physical reactions, such as sweating, trouble breathing, nause, or a pounding heart
20. I had dreams about it
21. I felt watchful and on-guard
22. I tried not to talk about it

IES-R Total score
Impact of event score qualitative
IES-R Intrusion
IES-R Avoidance
IES-R Hyperarousal

Sleep
How good is your sleep quality? "0" means extremely poor. "10" means excellent.*
What is your height in cm?*
What is your weight in kg?*
BMI
BMI score more than 35
Age over 50
Gender is male

	No	Yes
Do you snore loudly (loud enough to be heard through closed doors or your bed-partner elbows you for snoring at night)?
Do you often feel tired, fatigued, or sleepy during the daytime (tired enough that you could fall asleep while driving)?
Has anyone observed you stop breathing or choking/gasping during your sleep?
Do you have or are you being treated for high blood pressure?

STOP-BANG 4 questions score
STOP-BANG total score on 7
STOP-BANG qualitative

Please indicate the number that best describes your answer.Please rate the CURRENT (i.e. LAST 2 WEEKS) SEVERITY of your insomnia problem(s). *

	None	Mild	Moderate	Severe	Very severe
1. Difficulty falling asleep
2. Difficulty staying asleep
3. Problems waking up too early

	Very satisfied	Satisfied	Moderately satisfied	Dissatisfied	Very dissatisfied
4. How satisfied or dissatisfied are you with your CURRENT sleep pattern

	Not at all noticeable	A little	Somewhat	Much	Very much noticeable
5. How NOTICEABLE to others do you think your sleep problem is in terms of impairing the quality of your life?

	Not at all worried	A little	Somewhat	Much	Very much worried
6. How WORRIED/DISTRESSED are you about your current sleep problem?

	Not at all interfering	A little	Somewhat	Much	Very much interfering
7. To what extent do you consider your sleep problem to INTERFERE with your daily functioning (e.g. daytime fatigue, mood, ability to function at work/daily chores, concentration, memory, mood, etc.) CURRENTLY?

ISI Total Score
Should be Empty:

Introduction

General information

Current history

Pain history

Medication use

Functionality

Quality of Life

Sleep