Contact Details

Patient First Name *

Patient Last Name *

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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

Your Signature

Orofacial and TMJ Pain Questionnaire