Temporomandibular Disorder History Form

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    Basic Info:

    Today's Date:
    Date of Birth:
    Name:
    Address:
    Referred By:

    Major Reason for Current Evaluation

    1. Describe what you think the problem is:
    2. What do you think caused this problem?
    3. Describe, in order (first to last), what you expect from your treatment:

    General History

    1. Are you presently under the care of a physician or have you been in the past year?
    Physician's Name:
    Condition treated:
    Treatment:
    Medication(s) you are currently taking:
    2. How would you describe your overall physical health (0 is poor, 10 is excellent)?
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    3. How would you describe your dental health (0 is poor, 10 is excellent)?
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    Dentist's name:
    Date of last appointment:
    4. Have you had any major dental treatment in the last two years?
    Date(s) of Third Molar (wisdom tooth) extractions?

    Facial Injury/Trauma History

    1. Is there any childhood history of falls, accidents or injury to the face or head?
    Describe:
    2. Is there any recent history of trauma injury to the face or head? (Auto accident, sports injury, facial impact)
    Describe:
    3. Is there any activity that holds the head or jaw in an imbalanced position? (Phone, swimming, instrument)
    Describe:

    Temporomandibular Disorder History

    1. Have you ever been examined for a TMD problem before?
    By whom:
    When:
    2. What was the nature of the problem? (Pain, noise, limitation of movement) 3. What was the duration of the problem?
    Months:
    Years:
    Is this a new problem? YesNo
    4. The problem is:
    5. Have you ever had physical therapy for TMD? YesNo 6. Have you ever received treatment for jaw problems? YesNo
    By whom:
    When:
    What was the treatment? Bite SplintMedicationPhysical TherapyOcclusal AdjustmentOrthodonticsCounselingSurgeryOther
    Please explain:

    Current Medications/Appliances

    1. Degree of currend TMD pain (0 is none, 10 is extreme):
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    2. Frequency of TMD pain:
    Is there a pattern for the TMD problem?
    3. Are you taking medication for the TMD problem?
    What type?
    How long?
    Who prescribed the medication?
    3a. Are the medications that you take effective?
    Please explain:
    4. Are you aware of anything that makes your pain words?
    Please explain:
    5. Does your jaw make noise? YesNo
    RIGHT SIDE
    Please explain:
    LEFT SIDE
    Please explain:
    6. Does your jaw lock open? YesNo
    When did this first occur?
    How often?
    7. Has your jaw ever locked closed or partially closed? YesNo
    When did this first occur?
    How often?
    8. Have any applicances ever been prescribed? YesNo
    By whom?
    When?
    Describe the appliance: 8a. Are these appliances effective? YesNo
    9. Is there any additional information that can help us in this area?

    Current Stress Factors:

    (please check all that apply to you)

    1. Do you clench your teeth together under stress?
    2. Do you grind/clench your teeth at night?
    3. Do you sleep with an unusual head position?
    4. Are you aware of any habits or activities that may aggravate this condition?
    Please explain:

    Symptoms

    Please check each that apply to you.

    A. HEAD PAIN, HEADACHES, FACIAL PAIN

    B. EYE PAIN OR EAR ORBITAL PROBLEMS

    C. MOUTH, FACE, CHEEK AND CHIN PROBLEMS

    D. TEETH AND GUM PROBLEMS

    E. JAW AND JAW JOINT (TMD) PROBLEMS

    F. PAIN, EAR PROBLEMS, POSTURAL IMBALANCES

    G. OTHER (please explain)

    THROAT PROBLEMS

    I. NECK AND SHOULDER PAIN

    In your own words, tell us where your pain is and how intense it is:

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