Have you ever had any major dental treatment in the last two years?
Yes
No
Date of Appointment:
What type of Treatment did you receive?:
Orthodontics
Periodontics
Oral Surgery
Restorative
Date(s) of Third Molar (wisdom tooth) extraction(s):
Facial Injury/Trauma History?
Is there any childhood history of falls, accidents, or injury to the face or head? Describe:
Is there any recent history of trauma to the head or face? (Auto accident, sports injury, facial impact):
Is there any activity which holds the head or jaw in an imbalanced position? (Phone, swimming, instrument):
TMD Treatment History
If Yes, by whom?:
When:
What was the nature of the problem? (Pain, noise, limitation of movement):
What was the duration of the problem?
Years:
Months:
If yes, by whom?:
When?:
Is the problem getting better, worse or staying the same?:
If yes, by whom?:
When:
What was the treatment:
Bite Splint
Medication
Physical Therapy
Occlusal Adjustment
Orthodontics
Counseling
Surgery
Other (Please Explain):
Current Medications or Appliances
Degree of TMD Pain on a scale from 0 to 10. Zero being No Pain and Ten being Severe Pain:
Frequency of TMD pain:
Daily
Weekly
Monthly
Semi-Annually
Is there a pattern related to the pain occurrence?
Upon Waking
Morning
Afternoon
Evening
After Eating
Are you taking medication for the TMD Problem? If so what type?:
Are you aware of anything that makes your pain worse?
Yes
No
If yes, What?:
Does your jaw make noise?
Yes
No
Right Jaw :
Clicking
Popping
Grinding
Other:
Left Jaw :
Clicking
Popping
Grinding
Other:
Does your Jaw lock open?
Yes
No
When did this first occur?:
Has your jaw ever locked partially closed?
Yes
No
When did this first occur?:
Have dental appliances been prescribed?
Yes
No
If Yes by whom?:
Describe:
Are these appliances effective?
Yes
No
Is there any additional information that can help us in this area?:
Current Stress Factors
Death of Spouse
Business Adjustment
Financial Problems
Fired from Work
Death of Family Member
Marital Separation
Major Illness or Injury
Divorce
Pregnancy
Marital Reconciliation
New Person joins Family
Major Health change in Family
Pending Marriage
Carrier Change
Taking on Debit
Other
Habit History
Symptoms
Head Pain, Headaches, Facial Pain
Forehead
Left Side
Right Side
Temples
Left
Right
Migraine Type Headaches
Cluster Headaches
Maxillary Sinus Headaches (under the eyes)
Occipital Headaches (back of the head with or Clicking, Popping Jaw Joints Frequent Coughing/Clearing Throat without shooting pain)
Hair and/or Scalp Painful to Touch
Eye Pain or Ear Orbital Problems
Eye Pain - Above, Below or Behind
Bloodshot Eyes
Blurring of Vision
Bulging Appearance
Pressure Behind Eyes
Light Sensitivity
Watering of Eyes
Drooping of the Eyelids
Mouth, Face, Cheek & Chin Problems
Discomfort
Limited Opening
Inability to Open Smoothly
Teeth and Gum Problems
Tooth Pain
Looseness and/or Soreness of Back Teeth
Clenching, Grinding at Night
Jaw & Jaw Joint (TMD) Problems
Clicking, Popping Jaw Joints
Grating Sounds
Jaw Locking Opened or Closed
Pain in Cheek Muscles
Uncontrollable Jaw or Tounge Movements
Pain, Ear Problems, Postural Imbalances
Hissing, Buzzing, Ringing or Roaring Sounds
Ear Pain without Infection
Clogged, Stuffy, Itchy Ears
Balance Problems - "Vertigo"
Throat Problems
Laryngitis
Vice Fluctuations
Tightness of Throat
Swallowing Difficulties
Sore Throat
Pain in the Hard Palate
Salivation
Tounge Pain
Felling of Foreign Object in Throat
Frequent Coughing or Clearing Throat
Neck and Shoulder Pain
Reduced Mobility and Range of Motion
Stiffness
Neck Pain
Tired, Sore Neck Muscles
Back Pain, upper and lower shoulder
Other Pain
If so, please describe in the box provided:
Describe: