Name:____________________________ D



KENEDY RUTH DENTAL CENTRE

27 Ruth Ave, Unit 6A, Brampton, ON L6Z4R2

905-846-1575

Name: ____________________________ SEX: _____ D.O.B.___________ Chart # __________________

1. Do you have jaw joint pain?

( ) No ( ) Right ( ) Left ( ) Both

( ) one day per week ( ) 2-3 days per week ( ) 4-7 days per week

2. Do you have ear pain?

( ) one day per week ( ) 2-3 days per week ( ) 4-7 days per week

3. Do you have other pain in the jaw, face, or neck?

( ) No ( ) Right ( ) Left ( ) Both

( ) one day per week ( ) 2-3 days per week ( ) 4-7 days per week

4. Are you aware of your jaw making noises?

During Chewing ( ) None ( ) Right ( ) Left ( ) Both

During extreme opening ( ) none ( ) Right ( ) Left ( ) both

5. Do you have any other joint problems?

( ) No ( ) Yes If yes what joints? __________________________

6. Do you have pain when you chew?

( ) No ( ) Right ( ) Left ( ) Both

7. Do you have pain when you open wide or take a big bite?

( ) No ( ) Right ( ) Left ( ) Both

8. Does the pain or discomfort interfere with your work activities or your life-style?

( ) No ( ) Yes Which? _______________________________

9. Are certain foods difficult to chew?

( ) No ( ) hard, tough foods ( ) lettuce ( ) thick sandwiches

10. Do you prefer to chew on one side?

( ) No If yes, is there a preferred side for chewing? ( ) Right ( ) Left

11. Are you taking any medications for your jaw problem? How Often?

( ) No ( ) Yes

( ) one day per week ( ) 2-3 days per week ( ) 4-7 day per week

12. Have you ever been in an accident or received a blow to the face?

( ) No ( ) Yes Describe injury ______________________________

13. Are you aware of clenching or grinding your teeth?

( ) No If yes, when and how often?

( ) In sleep ( ) one day per week ( ) 2-3 days per week ( ) 4-7 days per week

( ) In tension ( ) one day per week ( ) 2-3 days per week ( ) 4-7 days per week

( ) Both ( ) one day per week ( ) 2-3 days per week ( ) 4-7 days per week

14. Have you ever had your teeth ground on to make then fit together better?

( ) No ( ) Yes Year? ________

15. Has your jaw ever locked?

( ) No

( ) Open (when you can't close your mouth)

( ) Closed (when you can't open your mouth)

( ) Both

16. Have you ever had general anesthesia?

( ) No ( ) Yes please specify ________________________________________

17. Do you have any of the following habits?

( ) Fingernail biter ( ) Pipe stem biter ( ) Wide open mouth procedure

( ) Gum chewer ( ) Play musical instrument

( ) Pencil biter ( ) Hand to jaw position

( ) Cheek biter ( ) Telephone on shoulder

21. Do you have headaches? ( ) No

If yes, how often and where is it located?

Frontal ( ) Left ( ) Right ( ) Both ( ( ) 1 day/week ( ) 2-3 days/week ( ) 4-7 days/week Temporal ( ) Left ( ) Right ( ) Both ( ( ) 1 day/week ( ) 2-3 days/week ( ) 4-7 days/week

Back/Neck ( ) Left ( ) Right ( ) both ( ( ) 1 day/week ( ) 2-3 days/week ( ) 4-7 days/week

On the scale indicate your HEADACHE pain intensity. The left side represents NO PAIN and the right side represents EXTREME PAIN as bad as you could imagine. Draw a line from left to right to demonstrate your pain.

NO EXTREME

24. RIGHT SIDE PAIN 0───1───2───3───4───5───6───7───8───9───10 PAIN

NO EXTREME

25. LEFT SIDE PAIN 0───1───2───3───4───5───6───7───8───9───10 PAIN

26. On the scale indicate your JAW pain intensity. The left side represents NO PAIN and the right side represents EXTREME PAIN as bad as you could imagine. Draw a line from left to right to demonstrate your pain intensity.

NO EXTREME

RIGHT SIDE PAIN 0───1───2───3───4───5───6───7───8───9───10 PAIN

NO EXTREME

LEFT SIDE PAIN 0───1───2───3───4───5───6───7───8───9───10 PAIN

27. Have you had any dental work recently?

( ) No ( ) Yes Please encircle (extractions, orthodontics, fillings, crowns, dentures)

28. Have you had splint (mouth piece) treatment for your jaw joint problem?

( ) No ( ) Yes what type? _______________.

29. Do you feel nervous?

( ) No ( ) Questionable ( ) Probable ( ) Definite

30. Are you under emotional tension?

( ) No ( ) Questionable ( ) Probable ( ) Definite

31. When does this problem bother you more?

( ) In the morning ( ) While trying to sleep

( ) Mid-afternoon ( ) No specific time

( ) Evening ( ) All of the time ( ) Not at all

31. Does your TMJ create emotional stress?

( ) No ( ) Yes

32. Does anyone else in your family have jaw pain?

( ) No ( ) Yes Specify ________________________________

33. How long has this problem bothered you (in weeks)? _____________

[pic]

[pic]

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download