Index of Head, , and Facial plus TMJ Dysfunction Name______Age______Today’s Date______

Please indicate your main or chief complaints in Please check symptoms you have had or are currently experiencing: order of their current importance: EYE PAIN AND ORBITAL PROBLEMS TEETH AND GUM PROBLEMS 1. ______Eye pain, above, below, behind Clenching and grinding at night (bruxism) Pressure behind the eyes (retro-orbital) Looseness and or soreness of back teeth 2. ______Watering of the eyes (lacrimation) Tooth pain ()

3. ______HEAD AND PAIN JAW AND JAW JOINT PROBLEMS Forehead (frontal) pain or headache Clicking of the jaw joints Additional Comments: Temple (temporal) pain or headache right left both ______“Migraine” type headache Popping of jaw joints “Cluster” headache right left both ______Maxillary sinus pain or headache (under the Grating sounds (crepitus) eyes) right left both Please draw areas of pain or distress on the Posterior (back of the head) with picture below: Jaw locking opened or closed or without shooting (occipital) Pain in cheek muscles Hair and scalp painful to touch (parietal) Uncontrollable jaw, tongue movements Other type of headache or head pain Avoiding certain foods If so, please list: ______If so, please list: ______MOUTH, CHEEK, AND CHIN PROBLEMS EAR AND BALANCE PROBLEMS Discomfort Hissing, bussing, ringing, roaring (tinnitus) Limited opening Diminished hearing (subjective hearing loss) Inability to open smoothly, evenly Ear pain without infection (otalgia) Jaw deviates to one side when opening Clogged, stuffy, “itchy” ears; feeling of fullness Balance problems, “vertigo” (disequilibrium) THROAT PROBLEMS NECK AND SHOULDER PROBLEMS Lack of mobility, reduced range of movement Tightness of throat Stiffness without infection (coryza) Neck pain Frequent coughing or constant clearing of throat Tired, sore neck muscles Feeling of foreign object in throat Shoulder aches Tongue pain (glossalgia) Upper and/or lower Pain in the hard palate (posterior area) ______Martha E. Rich, D.M.D. 833 SW 11th Avenue, Suite 405 Portland, OR 97205 503-228-6870

Type: Practitioner: Frequency:

Pain Medications: Anti-Depressants: Muscle Relaxants:

please answer the following questions