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)? _____________
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