History Form for Patient with Temporomandibular Disorder

We would like to thank you for referring clients to our office. In an effort to provide the best service, we ask you to fill out this form as completely as possible. Thank you for your cooperation.

Patient Information

Date:

Date of Birth:

Address:

City:

State/Province:

Zip/Postal Code:

Referred By:

Major Reason for Current Evaluation

Describe what you think the problem is:

Describe, in order (first to last), what you expect from your treatment:

General History

Are you currently under the care of a physician or have you been in the last year?

Yes No

What do you think caused this problem?:

Physicians Name:

Treatment:

Names of Medication(s) you are currently taking:

On a scale from 0 to 10. Zero being Poor and Ten being Excellent; How would you describe your overall physical health?:

On a scale from 0 to 10. Zero being Poor and Ten being Excellent; How would you describe your dental health:

Dentist's name:

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

Have you ever been examined for a TMD problem before?

Yes No

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:

Is this a new problem

Yes No

Have you ever had physical

therapy for TMD Yes No

If yes, by whom?:

When?:

Is the problem getting better, worse or staying the same?:

Have you ever received treatment for jaw problems?

Yes No

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

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

Do you clench your teeth together under stress?

Yes no don't know

Do you grind or clench your teeth at night?

Yes no don't know

Do you sleep with an unusual head position?

Yes no don't know

Are you aware of any habits or activities that may aggravate this condition?

Yes no don't know Describe:

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:

Verification

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