Index of Head, Neck, and Facial Pain Plus TMJ Dysfunction Name______Age______Today’S Date______
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Index of Head, Neck, and Facial Pain 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 (toothache) 3. _______________________________________ HEAD AND HEADACHE 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 headaches (back of the head) with picture below: Jaw locking opened or closed or without shooting pains (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 Sore throat 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 back pain 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 .