What are the chief concerns for which you are seeking treatment?
Orthodontic:
Pain, Sleep or Airway:
Cosmetic, Restorative or other:
Please number the complaints with #1 being the most severe, #2 the next most severe, efc.
Symptoms from which you most desire relief:
TMD / PAIN COMPLAINTS:
#1 = the most severe symptom
Jaw clicking / grating
Dizziness
Jaw locking / stiffness
Morning headpain
Limited Mouth Opening:
Morning hoarsness
Teeth Grinding at night
Mouth Doesn't open straight
Pain When Chewing:
Jaw Pain:
Unstable Bite:
Headaches:
Facial Pain:
Neck Pain:
Ear Pain or stuffiness:
Ringing in the ears:
Difficulty Swallowing:
Facial Muscle fatigue:
Migranes:
Other:
Sleep / Breathing Complaints
CPAP intolearance
Difficulty falling asleep
Fatigue
Frequent Heavy Snoring
Frequent Heavy Snoringwhich affects the sleep of others
Gasping When Waking Up
Nighttime choking spells
Significant daytime drowsiness
Sleepy when driving
Witnessed apneic events (stopping breathing)
Sleep History
Sleep
Do you get to sleep well, stay asleep well, and wake up feeling rested?
Bruxism
Witnessed apneas
Clenching
Dry mouth
Waking up & having difficulty sleeping
Gasping
Awake
Awakens un-refreshed
Has morning headaches
Problematic Daytime Sleepiness
Naps:
Snoring
Snoring
Severity
Worse
CPAP:
Cpap:
Ck reason:
Other:
SPECIFIC SYMPTOMS
Check if head, neck, back and jaw joints are currently without pain or discomfort
Head Pain
Entire head (generalized)
Top of the head
Pain or discomfort on turning the head
Front of your head (frontal)
Back of your head
Temples
THROAT, NECK & BACK CONDITIONS
Back pain - lower
Back pain - middle
Back pain - upper
Constant feeling of a foreign object in throat
Difficulty in swallowing
Chronic sore throat
Limited movement of neck
Neck pain
Neck clicking, popping, or grating noises on movement
Numbness of hands or fingers
Chronic sinusitis
Tightness in throat
Thyroid enlargement
Sciatica
Scoliosis
Pain or discomfort moving arms or shoulders
Shoulder stiffness
Swelling in the neck
Swollen glands
MOUTH & NOSE RELATED CONDITIONS
Stuffiness at night
Pain or discomfort on yawning
Burning tongue
Frequent biting of cheek
Teeth clenching
Dry mouth
Broken teeth
Pain or discomfort on sneezing
Pain or discomfort on shouting:
Pain or discomfort while speaking
EAR-RELATED CONDITIONS
Ear pain
Tingling in the hands or fingers
Ear stuffiness
Pain in front of the ear
Tinnitus (ringing in the ears)
Pain behind the ear
Hearing loss:
EYE-RELATED CONDITIONS
Blurred vision
Eye pain
Pain or pressure behind eyes
LIST ANY TREATMENTS YOU HAVE HAD FOR THIS PROBLEM AND ALL HEALTH PROFESSIONALS THAT YOU ARE CURRENTLY SEEING:
HEAD PAIN NATURE
LOCATION DURATION
Which side are the headaches worse? (choose ONE)
Headache spreads to:
DURATION How long does your pain last?
How frequent is your pain?
SEVERITY ON A SCALE OF 0-10 0 = no pain, 10 = worst pain imaginable
Jaw Pain on a numeric pain scale
Headaches on a 0-10 pain scale
Neck Pain on a numeric pain scale
Facial Pain on a 0-10 pain scale
When are your symptoms worse?
PAIN NATURE
How would you describe the type of pain you experience?
How would you describe the type of pain you experience?
Is there anything you do that starts the pain?
Do you have days when the pain is so bad that you spend the whole day in bed?
When having pain, do you experience:
How often do you take medicine for the relief of pain?
HISTORY OF SYMPTOMS
