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Orofacial and TMJ Pain Questionnaire

    Contact Details

    Head Pain
    Do you get head pain in these areas? If so, fill out the details:
    (NB "Recent" is <6 months; "Chronic" is >6 months)

    Location

    Side

    Onset

    Severity

    Duration

    Frequency

    Genera- lised

    Frontal (front)

    Parietal (top)

    Occipital (back)

    Temporal (side)

    Do you have pain or discomfort in any of the following areas? If so, please indicate the approximate date the pain began.

    Jaw Pain

     

    Date

    Jaw pain with opening

    Jaw pain when chewing

    Jaw pain at rest

    Jaw Joint Sounds

     

    Date

    Jaw sounds with opening

    Jaw sounds when chewing

    Jaw sounds at rest

    Jaw Locking

     

    Date

    Jaw locks closed

    Jaw locks open

    Jaw Joint Symptoms

     

    Date

    Teeth clenching

    Jaw locks open

    Eye Related Conditions

     

    Date

    Blurred vision

    Double vision

    Eye Pain

    Pain/pressure behind eyes

    Extreme sensitivity to light

    Glasses/contact lenses

    Ear Related Conditions

     

    Date

    Buzzing in the ears

    Ear congestion

    Ear Pain

    Hearing loss

    Itchiness/stuffiness in ears

    Pain behind ear

    Pain in front of ear

    Recurrent ear infections

    Ringing in the ear

    Throat Related Conditions

     

    Date

    Chronic sore throat

    Difficulty swallowing

    Swollen glands

    Thyroid enlargement

    Tightness in throat

    Feeling of foreign object in throat

    Neck Related Conditions

     

    Date

    Limited movement of neck

    Neck pain

    Numbness in hands or fingers

    Swelling in neck

    Shoulder Related Conditions

     

    Date

    Shoulder pain

    Shoulder stiffness

    Tingling in hands or fingers

    Back Related Conditions

     

    Date

    Back pain - lower

    Back pain - middle

    Back pain - upper

    Sciatica

    Scoliosis

    Mouth and Nose Related Conditions

     

    Date

    Dry mouth

    Chronic sinusitis

    Frequent snoring

    Burning tongue

    Broken teeth

    Frequent biting of cheek

    Sleep Conditions

    Main sleep position

    Average hours of sleep per night?

    Is it easy to fall asleep?

    Do you wake often during the night?

    Do you feel rested upon waking?

    Gasping or choking during sleep?

    Do you stop breathing during sleep?

    Ever had a sleep study (PSG)?

    If yes, what were the results of the sleep study?

    Does any family member have the same or similar problem? If yes, please explain:

    Can you related your pain or condition to a motor vehicle accident or traumatic injury?

    Please list the NINE biggest symptoms you have, ranked from number 1 (most severe) to number 9 (least severe).

    Headache pain

    Ear pain

    Jaw pain

    Chewing pain

    Facial pain

    Eye pain

    Throat pain

    Neck pain

    Shoulder pain

    Back pain

    Limited mouth opening

    Jaw joint locking

    Jaw joint noises

    Ear congestion

    Sinus congestion

    Dizziness

    Tinnitus (ear ringing)

    Muscle twitching

    Vision problems

    Repeated kicking/jerking legs

    Swelling in ankles/feet

    Morning hoarseness

    Dry mouth upon waking

    Fatigue

    Difficulty falling asleep

    Tossing/turning during sleep

    Repeated awakening

    Unrefreshed after sleep

    Daytime drowsiness

    Frequent heavy snoring

    Gasping when waking

    Stopping breathing during sleep

    Night time choking spells

    Unable to tolerate CPAP

    Tooth grinding

    Tooth crowding

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