110 Professional Park Dr. Victoria, TX 77904

TMJ Patient Questionaire



    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

    Have you been previously diagnosed with Obstructive Sleep Apnea?
    When
    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
    Excessive movements
    Restless legs
    Frequency of nocturnal urination (# of times) per nt
    Getting up (# of times) per night.
    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:
    -
    -
    -
    -
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    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
    When did your condition first occur?
    What do YOU believe is the cause of your pain or condition?
    If Accident Date
    Is there anything that makes your pain or discomfort worse?
    Is there anything that makes your pain or discomfort better?
    What other information is important to your pain or condition?

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    Our office is conveniently located off East Mockingbird Lane, between John Stockbauer Rd., and Sam Houston Dr.

    ADDRESS

    110 Professional Park Dr.
    Victoria, TX 77904

    HOURS

    Mon - Thu
    8:00AM - 5:00PM