Trigeminal nerve study



Orofacial pain

Neuralgia

Trigeminal neuralgia Typical Atypical

Post herpetic neuralgia

Post traumatic neuralgia

Neurovascular

Migraine

Migrainous neuralgia

Giant cell arteritis

Cluster headaches

Tension headache

Trigeminal autonomic SUNCT SUNA

Idiopathic / Persistent

Burning mouth syndrome

Atypical facial pain

Atypical odontalgia

Other cause found

Non classifiable

Trigeminal nerve injury

Hospital number Patients sticker

|Date examination | |

|Date injury | |

|Mechanism of injury |ID block |

| |Surgery (TMS, Biopsy) |

| |Implant Other |

|Date repair |Improvement Y/N |

|Nerve | |

|RMH | |

|Comments: | |

|Pain Y/N |Evoked / Spontaneous What cause? At rest/ taste |

|Constant / Intermittent |/movement/cold |

|Pain descriptive |Dull / Sharp Burning/Ache |

| |Shooting / stabbing |

|Altered sensation Y/N |Numbness |

| |Paraesthesia pins/needles |

| |Allodynia |

| |Hyperalgesia |

| |Neuralgia |

|Function |Eating / tongue biting |

| |Drinking |

| |Sleeping |

| |Speaking |

| |Kissing |

| |Shaving / makeup |

| |Change in taste Y / N |

|no pain | worst pain imaginable |

TESTS

|CNTs Y/N |Questionnaire Y/N |

|EMG Y/N |Electrical Y/N |

|Thermal Y/N |Capsaicin Y/N |

|Ethyl Chloride Y/N |

|Photo Y/N |

|At rest |

|no pain | worst pain imaginable |

|Capsaicin |

|no pain | worst pain imaginable |

|Touch |

|no pain | worst pain imaginable |

|Spicy foods |

|no pain | worst pain imaginable |

|Cranial Nerves |

|I II III IV V a b c VI VII VIII IX X XII | |

Area

[pic]

|CNTs |Right |Left |

|Area % | | |

|Two point discrimination | | |

|SO | | |

|IO | | |

|UL | | |

|LL | | |

|Chin | | |

|Tongue lat | | |

|Tongue tip | | |

|Tongue vent | | |

|Thermal | | |

|Semmes Weinstein / Light touch | | |

|SO | | |

|IO | | |

|UL | | |

|LL | | |

|Chin | | |

|Tongue lat | | |

|Tongue tip | | |

|Tongue vent | | |

|Capsaicin | | |

|EC | | |

|Sharp/blunt | | |

|Lip | | |

|Tongue | | |

|Hypoalgesia | | |

|Pain threshold | | |

|Lip | | |

|Tongue | | |

|Palpation LN | | |

|Pain | | |

|Neuralgia | | |

|Papillae count | | |

|Subjective function | | |

|Moving point discrimination Static | | |

|Dynamic | | |

|Taste | | |

|Sweet | | |

|Sour | | |

|Bitter | | |

|Salt | | |

|Allodynia – static/moving | | |

|cold | | |

|taste | | |

|capsaicin | | |

TREATMENT HISTORY

On the list below, indicate Yes or No for each treatment listed. For each treatment recommended by a health care professional for your facial pain or jaw problem, indicate how helpful you found it. If recommended, how helpful was treatment?

|Recommended |If recommended, how helpful was treatment? |

| | | |Very |Somewhat |Not |Made |Did Not Do |

| |No |Yes |Helpful |Helpful |Helpful |Worse | |

|a. Mouth appliance (“bite plate,” “night guard,” | | | | | | | |

|“repositioning appliance,” “splint”) |0 |1 |1 |2 |3 |4 |5 |

|b. Physical therapy (heat, cold packs, stretching) | | | | | | | |

| |0 |1 |1 |2 |3 |4 |5 |

|c. Relaxation training/biofeedback |0 |1 |1 |2 |3 |4 |5 |

|d. Physical exercise (running, bicycling) |0 |1 |1 |2 |3 |4 |5 |

|e. Stress management/counseling |0 |1 |1 |2 |3 |4 |5 |

|f. Change of diet |0 |1 |1 |2 |3 |4 |5 |

|g. Muscle relaxant medications |0 |1 |1 |2 |3 |4 |5 |

|h. Analgesics or “painkillers” |0 |1 |1 |2 |3 |4 |5 |

|i. Anti-inflammatory medications |0 |1 |1 |2 |3 |4 |5 |

|j. Anti-depressant medications |0 |1 |1 |2 |3 |4 |5 |

|k. Anti-anxiety medications |0 |1 |1 |2 |3 |4 |5 |

|l. Other medications - please describe: | | | | | | | |

| | |0 |1 |1 |2 |3 |4 |5 |

| | |0 |1 |1 |2 |3 |4 |5 |

| | |0 |1 |1 |2 |3 |4 |5 |

|m. Bite adjustment |0 |1 |1 |2 |3 |4 |5 |

|n. Orthodontics |0 |1 |1 |2 |3 |4 |5 |

|o. Dental reconstruction (crowns, bridges) |0 |1 |1 |2 |3 |4 |5 |

|p. Muscle or joint injections |0 |1 |1 |2 |3 |4 |5 |

|q. Surgery |0 |1 |1 |2 |3 |4 |5 |

|r. Chiropractic manipulation |0 |1 |1 |2 |3 |4 |5 |

|s. Evaluation and/or referral |0 |1 |1 |2 |3 |4 |5 |

|t. Other treatment - please describe: | | | | | | | |

| |Dates Name specialty of clinician |0 |1 |1 |2 |3 |4 |5 |

| | |0 |1 |1 |2 |3 |4 |5 |

| | |0 |1 |1 |2 |3 |4 |5 |

MEDICATION USE

Do you require antibiotic medication before dental treatment? List all drugs and medications you are currently taking for any purpose.

| |Nonprescription Medications |

|Prescription Medications |(for example, aspirin, laxatives, antacids, diet pills |

| |herbal remedies, marijuana, other “street” drugs) |

|1. | |1. | |

|2. | |2. | |

|3. | |3. | |

|4. | |4. | |

|5. | |5. | |

|6. | |6. | |

SPECIALISTS SEEN

Type location date and treatment received

Type of specialist GMP, Ear Nose Throat, Neurologist, neurosurgeon, maxillofacial, dentist, acupuncture, cranio osteopathy, physio, speech therapist, other

|Type and date seen |Hospital |Treatment received / Diagnosis |

| | | |

| | | |

| | | |

| | | |

| | | |

| | | |

| | | |

| | | |

HAD Scale

Doctors are aware that emotions play an important part in illnesses and this questionnaire is designed to help your doctor know how you feel. Read each item and place a firm tick in the box opposite the reply, which comes closest to how you have been feeling in the past week.

Don’t take too long over your replies; your immediate reaction to each item will probably be more accurate than a long thought-out response.

Tick one box only in each section

|1 I feel tense or wound up: | |8 I feel as if I am slowed down: | |

|Most of the time |( |Nearly all the time |( |

|A lot of the time |( |Very often |( |

|Time to time, occasionally |( |Sometimes |( |

|Not at all |( |Not at all |( |

| | | | |

|2 I still enjoy the things I used to enjoy: | |9 I get a sort of frightened feeling like | |

|Definitely as much | |“butterflies” in the stomach: |( |

|Not quite so much |( |Not at all |( |

|Only a little |( |Occasionally |( |

|Hardly at all |( |Quite often |( |

| |( |Very often | |

|3 I get a sort of frightened feeling as if | | | |

|something awful is about to happen: | |10 I have lost interest in my appearance: |( |

|Very definitely and quite badly | |Definitely |( |

|Yes, but not too badly |( |I don’t take so much care as I should |( |

|A little, but it doesn’t worry me |( |I may not take quite as much care |( |

|Not at all |( |I take just as much care as ever | |

| |( | | |

|4 I can laugh and see the funny side of things: | |11 I feel restless as if I have to be on the move: | |

|As much as I always could | |Very much indeed |( |

|Not quite so much now | |Quite a lot |( |

|Definitely not so much now |( |Not very much |( |

|Not at all |( |Not at all |( |

| |( | | |

|5 Worrying thoughts go through my mind: |( |12 I look forward with enjoyment to things: |( |

|A great deal of the time | |As much as I ever did |( |

|A lot of the time | |Rather less than I used to |( |

|From time to time bur not too often | |Definitely less than I used to |( |

|Only occasionally |( |Hardly at all | |

| |( | | |

|6 I feel cheerful |( |13 I get sudden feelings of panic: |( |

|Not at all |( |Very often indeed |( |

|Not often | |Quite often |( |

|Sometimes | |Not very often |( |

|Most of the time |( |Not at all | |

| |( | | |

| |( |14 I can enjoy a good book or radio or TV programme:| |

|7 I can sit at ease and feel relaxed: |( |Often |( |

|Definitely | |Sometimes |( |

|Usually | |Not often |( |

|Not often | |Very seldom |( |

|Not at all |( | | |

| |( | | |

| |( | | |

| |( | | |

McGill Questionnaire

NAME: DATE:

Circle the word that describes how your pain feels right now:

Nil

Mild

Moderate

Severe

Most severe

Circle the words below that best describe your current pain.

Use only one word in each group.

Leave out any group if the words are unsuitable.

|1 |2 |3 |4 |

|Flickering |Jumping |Pricking |Sharp |

|Quivering |Flashing |Boring |Cutting Lacerating |

|Pulsing |Shooting |Drilling | |

|Throbbing | |Stabbing | |

|Beating | |Lancinating | |

|Pounding | | | |

|5 |6 |7 |8 |

|Pinching |Tugging |Hot |Tingling |

|Pressing |Pulling |Burning |Ithcy |

|Gnawing |Wrenching |Scalding |Smarting Stinging |

|Cramping | |Searing | |

|Crushing | | | |

|9 |10 |11 |12 |

|Dull |Tender |Tiring |Sickening |

|Sore |Taut |Exhausting |Suffocating |

|Hurting |Rasping | | |

|Aching |Splitting | | |

|Heavy | | | |

|13 |14 |15 |16 |

|Fearful |Punishing |Wretched |Annoying |

|Frightful |Gruelling |Blinding |Troublesome |

|Terrifying |Cruel | |Miserable |

| |Vicious | |Intense |

| |Killing | |Unbearable |

|17 |18 |19 |20 |

|Spreading |Tight |Cool |Nagging |

|Radiating |Numb |Cold |Nauseating |

|Penetrating |Drawing |Freezing |Agonizing |

|Piercing |Squeezing | |Dreadful |

| |Tearing | |Torturing |

SF36 Health Survey

INSTRUCTIONS: This set of questions asks for your views about your health.

This information will help keep track of how you feel and how well you are able to do your usual activities. Answer very question by marking the answer as indicated. If you are unsure about how to answer a uestion please give the best answer you can.

1. In general, would you say your health is: (Please tick one box.)

Excellent _

Very Good _

Good _

Fair _

Poor _

2. Compared to one year ago, how would you rate your health in general now? (Please tick one box.)

Much better than one year ago _

Somewhat better now than one year ago _

About the same as one year ago _

Somewhat worse now than one year ago _

Much worse now than one year ago _

3. The following questions are about activities you might do during a typical day. Does your health

now limit you in these activities? If so, how much? (Please circle one number on each line.)

Activities

Yes, Limited A Lot Limited A Little Not Limited At All

3(a) Vigorous activities, such as running, lifting heavy objects, participating in strenuous sports

Yes, Limited A Lot Limited A Little Not Limited At All

3(b) Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf

Yes, Limited A Lot Limited A Little Not Limited At All

3(c) Lifting or carrying groceries

Yes, Limited A Lot Limited A Little Not Limited At All

3(d) Climbing several flights of stairs

Yes, Limited A Lot Limited A Little Not Limited At All

3(e) Climbing one flight of stairs

Yes, Limited A Lot Limited A Little Not Limited At All

3(f) Bending, kneeling, or stooping

Yes, Limited A Lot Limited A Little Not Limited At All

3(g) Waling more than a mile

Yes, Limited A Lot Limited A Little Not Limited At All

3(h) Walking several blocks

Yes, Limited A Lot Limited A Little Not Limited At All

3(i) Walking one block

Yes, Limited A Lot Limited A Little Not Limited At All

3(j) Bathing or dressing yourself

Yes, Limited A Lot Limited A Little Not Limited At All

4. During the past 4 weeks, have you had any of the following problems with your work or other

regular daily activities as a result of your physical health? Yes No

4(b) Accomplished less than you would like Yes No

4(c) Were limited in the kind of work or other activities Yes No

4(d) Had difficulty performing the work or other activities (for example, it took

extra effort) Yes No

5. During the past 4 weeks, have you had any of the following problems with your work or other

regular daily activities as a result of any emotional problems (e.g. feeling depressed or anxious)?

Yes No

5(a) Cut down on the amount of time you spent on work or other activities Yes No

5(b) Accomplished less than you would like Yes No

5(c) Didn’t do work or other activities as carefully as usual Yes No

6. During the past 4 weeks, to what extent has your physical health or emotional problems interfered

with your normal social activities with family, friends, neighbours, or groups? (Please tick one box.)

Not at all _

Slightly _

Moderately _

Quite a bit _

Extremely _

7. How much physical pain have you had during the past 4 weeks? (Please tick one box.)

None _

Very mild _

Mild _

Moderate _

Severe _

Very Severe _

8. During the past 4 weeks, how much did pain interfere with your normal work (including both work

outside the home and housework)? (Please tick one box.)

Not at all _

A little bit _

Moderately _

Quite a bit _

Extremely _

9. These questions are about how you feel and how things have been with you during the past 4

weeks. Please give the one answer that is closest to the way you have been feeling for each item.

(Please circle one number on each line.)

1. All of the Time

2. Most of the Time A Good Bit of the Time

3. Some of the Time

4. A Little of the Time

5. None of the Time

9(a) Did you feel full of life? 1 2 3 4 5 6

9(b) Have you been a very nervous person? 1 2 3 4 5 6

9(c) Have you felt so down in the dumps that nothing could cheer you up? 1 2 3 4 5 6

9(d) Have you felt calm and peaceful? 1 2 3 4 5 6

9(e) Did you have a lot of energy? 1 2 3 4 5 6

9(f) Have you felt downhearted and blue? 1 2 3 4 5 6

9(g) Did you feel worn out? 1 2 3 4 5 6

9(h) Have you been a happy person? 1 2 3 4 5 6

9(i) Did you feel tired? 1 2 3 4 5 6

10. During the past 4 weeks, how much of the time has your physical health or emotional problems

interfered with your social activities (like visiting with friends, relatives etc.) (Please tick one box.)

All of the time _

Most of the time _

Some of the time _

A little of the time _

None of the time _

11. How TRUE or FALSE is each of the following statements for you?

(Please circle one number on each line.) Definitely

True Mostly True Don’t Know Mostly False DefinitelyFalse

11(a) I seem to get sick a little easier than other people 1 2345

11(b) I am as healthy as anybody I know 1 2 3 4 5

11(c) I expect my health to get worse 1 2 3 4 5

11(d) My health is excellent 1 2 3 4 5

Thank You

BPI

Temporomandibular Joint pain / Orofacial Pain

Hospital number Patients sticker

|Date examination | |

|Date started | |

|Precipitating episode? |Trauma |

|Injury |Surgery (TMS, Bx) |

| |Implant Other |

|Previously treated Y/N |Improvement Y/N |

|Right Left Bilateral |Other joint pains? |

|RMH |Comments: |

|Pain Y/N |Evoked / Spontaneous What cause? At rest/ taste |

|Constant / Intermittent |/movement/cold |

|Frequency | |

|Pain descriptive |Dull / Sharp Burning/Ache |

| |Shooting / stabbing |

|Pain centre |Radiation to |

|Function |Eating |

| |Drinking |

| |Sleeping |

| |Speaking |

|At rest | |

|no pain |worst pain imaginable |

|Eating | |

|no pain |worst pain imaginable |

|Opening | |

|no pain |worst pain imaginable |

|Pain worse |Morning / evening |

|Diet altered Y/N |Bruxist |

|Gum chewing |Clencher |

TESTS

|Joint examination | |

|Trismus Y/N |Opening max (mm) |

| |Opening deviation |

|Full lateral movement |Swelling / asymmetry R-L |

|Centre line coincident Y/N |Max R-L Mandible R-L (mm) |

|Pain on palpation joints Y/N |Chin midline |

|Clicking R – L |Crepitus |

|Pre Mid Post | |

|Locked opening |Locked closing |

|Occlusion |Ant open bite |

|Class I II III |Post open bite |

|Attrition | |

|Questionnaire Y/N |

|Cranial Nerves |

|I II III IV V a b c VI VII VIII IX X XII | |

Area

TREATMENT HISTORY

On the list below, indicate Yes or No for each treatment listed. For each treatment recommended by a health care professional for your facial pain or jaw problem, indicate how helpful you found it. If recommended, how helpful was treatment?

|Recommended |If recommended, how helpful was treatment? |

| | | |Very |Somewhat |Not |Made |Did Not Do |

| |No |Yes |Helpful |Helpful |Helpful |Worse | |

|a. Mouth appliance (“bite plate,” “night guard,” | | | | | | | |

|“repositioning appliance,” “splint”) |0 |1 |1 |2 |3 |4 |5 |

|b. Physical therapy (heat, cold packs, stretching) | | | | | | | |

| |0 |1 |1 |2 |3 |4 |5 |

|c. Relaxation training/biofeedback |0 |1 |1 |2 |3 |4 |5 |

|d. Physical exercise (running, bicycling) |0 |1 |1 |2 |3 |4 |5 |

|e. Stress management/counseling |0 |1 |1 |2 |3 |4 |5 |

|f. Change of diet |0 |1 |1 |2 |3 |4 |5 |

|g. Muscle relaxant medications |0 |1 |1 |2 |3 |4 |5 |

|h. Analgesics or “painkillers” |0 |1 |1 |2 |3 |4 |5 |

|i. Anti-inflammatory medications |0 |1 |1 |2 |3 |4 |5 |

|j. Anti-depressant medications |0 |1 |1 |2 |3 |4 |5 |

|k. Anti-anxiety medications |0 |1 |1 |2 |3 |4 |5 |

|l. Other medications - please describe: | | | | | | | |

| | |0 |1 |1 |2 |3 |4 |5 |

| | |0 |1 |1 |2 |3 |4 |5 |

| | |0 |1 |1 |2 |3 |4 |5 |

|m. Bite adjustment |0 |1 |1 |2 |3 |4 |5 |

|n. Orthodontics |0 |1 |1 |2 |3 |4 |5 |

|o. Dental reconstruction (crowns, bridges) |0 |1 |1 |2 |3 |4 |5 |

|p. Muscle or joint injections |0 |1 |1 |2 |3 |4 |5 |

|q. Surgery |0 |1 |1 |2 |3 |4 |5 |

|r. Chiropractic manipulation |0 |1 |1 |2 |3 |4 |5 |

|s. Evaluation and/or referral |0 |1 |1 |2 |3 |4 |5 |

|t. Other treatment - please describe: | | | | | | | |

| | |0 |1 |1 |2 |3 |4 |5 |

| | |0 |1 |1 |2 |3 |4 |5 |

| | |0 |1 |1 |2 |3 |4 |5 |

. DURING THE PAST SIX MONTHS, HOW OFTEN HAVE YOU HAD EACH OF THE FOLLOWING JAW SYMPTOMS?

|How often… |Never |Sometimes |Often |Always |

| | | | | |

|a. Does your jaw CLICK or POP when you open or close your mouth or when chewing? | | | | |

| |0 |1 |2 |3 |

|b. Does your jaw make a GRATING or GRINDING noise when it opens and closes or when chewing? | | | | |

| |0 |1 |2 |3 |

|c. Do your JAW JOINT NOISES prevent you from doing activities that you would otherwise do? | | | | |

| |0 |1 |2 |3 |

|d. Does your jaw ACHE or FEEL STIFF when you wake up in the morning? | | | | |

| |0 |1 |2 |3 |

|e. Does your jaw HURT WHEN YOU CHEW or shortly after eating? |0 |1 |2 |3 |

|f. Does ache or pain in your jaw LIMIT YOUR ABILITY TO CHEW to the extent that it is difficult| | | | |

|to eat? |0 |1 |2 |3 |

|g. Do you wake up in the morning with HEADACHES? |0 |1 |2 |3 |

|h. Do you have NOISES or RINGING in your ears? |0 |1 |2 |3 |

|i. Do your ears feel CONGESTED? |0 |1 |2 |3 |

|j. Have you been told, or do you notice, that you GRIND your teeth or CLENCH your jaw while | | | | |

|sleeping at night? |0 |1 |2 |3 |

|k. Does limited ability to use your jaws PREVENT you from doing ACTIVITIES that you would | | | | |

|otherwise do? |0 |1 |2 |3 |

|l. Have you ever had your jaw LOCK or CATCH so that it won’t open all the way? (If Never, go | | | | |

|to question “n”) |0 |1 |2 |3 |

|m. Was this locking or catching severe enough to interfere with your ABILITY TO EAT? | | | | |

| |0 |1 |2 |3 |

|n. Have you ever had your jaw lock or catch so that YOU CAN’T CLOSE IT ALL THE WAY once it’s | | | | |

|open? |0 |1 |2 |3 |

|o. During the day, do you GRIND your teeth or CLENCH your jaw? |0 |1 |2 |3 |

|p. Does your BITE feel UNCOMFORTABLE or unusual? |0 |1 |2 |3 |

15. Was the CAUSE of your pain or jaw limitation related to any of the following factors? Do any of the following factors make your problem WORSE? For each of the items listed below, circle “C” for CAUSE or “W” for WORSE for each one that applies to your facial pain problem.

| |Oral Function, Habit and | |

|Physical Factors |Behavioral Factors |Stress-Related Factors |

|C |W |Dental Treatment |C |W |Chewing, smiling, |C |W |Family, work, school, or |

| | |Type | | | |yawning, or laughing | | |other stress |

| | |Date | | | | | | | |

| | | |C |W |Clenching, grinding |C |W |Emotional upset |

|C |W |Accident | | | | | | |

| | |Type | |C |W |Nail biting or other oral |C |W |Worry or anxiety |

| | |Date | | | |habits | | | |

| | | | | | |C |W |Feeling “blue”/depression |

|C |W |Other: | |C |W |Other: | | | | |

| | | | | | |C |W |Other: | |

| | |Date | | | | | | | |

|16. Are your symptoms better or worse at the following times? |17. What activities does your present jaw problem prevent or limit you from doing? |

| |Better |Worse |No Difference |N/A |No Yes | |No Yes | |

|Upon awakening |1 |2 |3 |4 |0 1 |Chewing |0 1 |Swallowing |

|During the day |1 |2 |3 |4 |0 1 |Drinking |0 1 |Cleaning teeth or face |

|In the evening |1 |2 |3 |4 |0 1 |Exercising |0 1 |Yawning |

|At work |1 |2 |3 |4 |0 1 |Eating hard foods |0 1 |Sexual activity |

|At home |1 |2 |3 |4 |0 1 |Eating soft foods |0 1 |Talking |

| | | | | |0 1 |Smiling/laughing |0 1 |Having your usual facial |

| | | | | | | | |appearance |

18. PAIN IMPACT

|a. About how many days in the LAST SIX MONTHS have you been kept from your usual activities (work, school, housework) because of facial pain? |

|For example: EVERY DAY = 180 days, EVERY OTHER DAY = 90 days, etc. |

Days

|b. In the PAST SIX MONTHS, how much has facial pain interfered with your daily activities rated on a scale from 0 to 10 where 0 is “No interference” and |

|10 is “Unable to carry on any activities”? |

| |

| |0 |1 |2 |

| |

|c. In the PAST SIX MONTHS, how much has facial pain interfered with your ability to take part in recreational, social and family activities? |

| |

| |0 |1 |2 |

| |

|d. In the PAST SIX MONTHS, how much has facial pain interfered with your ability to work (including housework)? |

| |

| |0 |1 |2 |

| |

|e. Based on all the things you do to cope or deal with your facial pain, on an average day, how much control do you feel you have over it? |

| |

| |0 |1 |2 |3 |4 |5 |6 | |

| |No control | Some control | |Complete control |

| |

|f. Based on all the things you do to cope or deal with your facial pain, on an average day, how much are you able to decrease it? |

| |

| |0 |1 |2 |3 |4 |5 |6 | |

|Can’t decrease it at all | Can decrease it somewhat | | Can decrease it completely |

19. GENERAL MEDICAL INFORMATION - PRESENT

Circle the symptoms listed below that you are PRESENTLY experiencing or HAVE EXPERIENCED FREQUENTLY during the past SIX MONTHS.

|GENERAL |MUSCULOSKELETAL |BEHAVIORAL |

|weight loss |joint pain |anger |

|weight gain |swollen joints |worry |

|change in appetite |muscle cramping |sleep difficulties |

|always hungry |arm/hand weakness |reduced social activities |

|always thirsty | |problems at work/home/school |

|frequent urination |GASTROINTESTINAL | |

|tend to feel hot |indigestion |SKIN CHANGES |

|tend to feel cold |reflux/heartburn |skin color changes |

|fatigue |nausea/vomiting |skin itching/burning |

|faint easily |constipation |other skin problems |

|night sweats |diarrhea |nail changes |

|bleed easily | | |

|bruise easily |CARDIOVASCULAR |NEUROLOGICAL |

| |shortness of breath with exertion |loss of muscle control/paralysis |

|NOSE/THROAT |racing or irregular heart beat |numbness/tingling |

|congested/runny nose |swollen ankles |handwriting changes |

|nose bleeds |cold ankles/feet |memory changes |

|nasal obstruction |chest pain/angina |neuropathy |

|sore throat | | |

|hoarseness/voice changes |RESPIRATORY |EARS |

|mouth breathing/ snoring |coughing spells |hearing loss |

|sleep apnea |cough up phlegm |ringing ears |

| |wheezing |earaches |

|HEAD & NECK |frequent colds |dizziness |

|neck pain |use more than 2 pillows to sleep |pressure/stuffiness in ears |

|neck lump/swelling | | |

|headache |EYES |OTHER PAIN |

|facial pain |vision changes |back pain |

|migraine |eye itching |abdominal pain |

|shoulder |dry eyes |arm pain |

| |eye pain |leg pain |

| | |other pain |

|[pic] Check here if you have none of the symptoms listed above. |

20. GENERAL MEDICAL INFORMATION

Would you say your health in general is excellent, very good, good, fair, or poor?

|1 Excellent |2 Very Good |3 Good |4 Fair |5 Poor |

21. How good a job do you feel you are doing in taking care of your health overall?

|1 Excellent |2 Very Good |3 Good |4 Fair |5 Poor |

22. Has there been a change in your general health in the past year? 0 No 1 Yes

23.

Your physician:

Phone Number: — —

24. Date of your last physical examination: / /

25. a. Are you currently being treated by a physician? 0 No 1 Yes

b. Are you currently being treated by a psychiatrist,

psychologist or mental health worker? 0 No 1 Yes

26. Do you engage in regular exercise? 0 No 1 Yes

27.HISTORY OF ILLNESS

Provide an answer for each item listed below. Check the “N” column for those conditions you have NEVER had, the “C” column for conditions you CURRENTLY have, and “P” column for the conditions you have had in the PAST.

|N |C |

|a difficult pregnancy |using birth control pills |

|irregular periods |PRESENTLY PREGNANT: ______ months pregnant |

|menstrual pains |going through menopause |

|a hysterectomy |postmenopausal |

|ovary(ies) removed |using hormone therapy |

|none of the above |none of the above |

30. MAJOR HOSPITALIZATIONS, SURGERIES, AND BLOOD TRANSFUSIONS

Date Reason

/ /

/ /

/ /

[pic] Check here if no hospitalizations, surgeries, or blood transfusions.

31. ALLERGIC OR UNUSUAL REACTIONS

Circle any of the following you have had an allergic or other unusual reaction to.

|Penicillin |Other drugs: |Other allergies (food, metals, etc.): |

|Sulfa | | | | |

|Aspirin | | | | |

|Opiates/codeine |Local anesthesia | | |

|Iodine |Latex | | |

[pic] Check here if no allergic or unusual reactions.

32. MEDICATION USE

Do you require antibiotic medication before dental treatment? List all drugs and medications you are currently taking for any purpose.

| |Nonprescription Medications |

|Prescription Medications |(for example, aspirin, laxatives, antacids, diet pills |

| |herbal remedies, marijuana, other “street” drugs) |

|1. | |1. | |

|2. | |2. | |

|3. | |3. | |

|4. | |4. | |

|5. | |5. | |

|6. | |6. | |

[pic] Check here if you are taking no prescription or nonprescription medications.

DOCTOR’S USE:

33. CAFFEINE, ALCOHOL AND TOBACCO USE

|a. Average number of caffeinated beverages you drink in a DAY. | |b. Average number of alcoholic beverages you drink in a WEEK. |

| | | | | | | | | | |

|Coffee |0 |1-2 |3+ | |Beer |0 |1-2 |3-5 |6+ |

|Tea |0 |1-2 |3+ | |Wine |0 |1-2 |3-5 |6+ |

|Cola |0 |1-2 |3+ | |Spirits/other |0 |1-2 |3-5 |6+ |

c. Have you EVER used tobacco products? 0 No 1 Yes

If Yes, circle the type(s) of tobacco products.

Cigarette Pipe/cigar Smokeless

Do you CURRENTLY use tobacco products? 0 No 1 Yes

If Yes, circle the average number of uses per DAY.

1 Less than 10 times/day 2 11-20 times/day 3 More than 20 times/day

How many years have you used a tobacco product?

1 Less than 5 years 2 6-10 years 3 11-20 years 4 More than 20 years

34. FAMILY MEDICAL HISTORY

Mark in either the “Y” for Yes or “N” for No column to indicate any of the following medical problems that have been present in your parents, brothers/sisters, or other close relatives.

|Y |N | |Y |N | |Y |N | |

| | |cancer (type: ____________) | | |allergic disorders | | |TMJ problems |

| | | | | |asthma | | | |

| | |genetic (inherited disease) | | |tuberculosis | | |rheumatoid arthritis |

| | | | | |arthritis | | |lupus erythematosus |

| | |stomach/intestinal problems | | |back pain | | |other systemic arthritic disease |

| | |kidney or bladder problems | | |headache or migraine | | |other immune system disease |

| | |liver disease | | |seizures | | | |

| | | | | |neurological disease | | |drug abuse |

| | |diabetes | | | | | |alcoholism |

| | | | | |high blood pressure | | | |

| | |anemia | | |heart disease | | |psychiatric illness |

| | |bleeding disorders | | |stroke | | |anxiety/panic attacks |

| | | | | | | | |depression |

| | | | | | | | |suicide or attempted suicide |

[pic] Check here if no one in your family has ever had any of the problems listed above.

DOCTOR’S USE:

35. PREVIOUS DENTAL CARE

a. Circle those items that describe your past dental care.

|Circle one: |Circle all that apply: | |

|Regular dental care |Wisdom tooth extractions |Bite adjustment |

|Emergency treatment only |Treatment for jaw trauma/fracture |Night guard/splint |

|Occasional dental care |Periodontal (gum) surgery |TMJ problems |

| |Root canal therapy |Facial pain |

| |Orthodontics |Other: |

| |Gum disease (pyorrhea, gingivitis, or | |

| |periodontal disease) | |

b. Would you say your ORAL HEALTH in general is:

|1 Excellent |2 Very Good |3 Good |4 Fair |5 Poor |

c. How good a job do you feel you are doing in taking care of your oral health?

|1 Excellent |2 Very Good |3 Good |4 Fair |5 Poor |

Date of your last regular dental visit: / /

|Name and address of your dentist: | |

| | |

| | |

DOCTOR’S USE:

36. SYMPTOM CHECKLIST

In the LAST MONTH, how much you have been distressed by:

| |Not at all |A little bit |Moderately |Quite a bit |Extremely |

|a. Headaches |1 |2 |3 |4 |5 |

|b. Nervousness or shakiness inside |1 |2 |3 |4 |5 |

|c. Faintness or dizziness |1 |2 |3 |4 |5 |

|d. Loss of sexual interest or pleasure |1 |2 |3 |4 |5 |

|e. Feeling easily annoyed or irritated |1 |2 |3 |4 |5 |

|f. Pains in the heart or chest |1 |2 |3 |4 |5 |

|g. Feeling low in energy, slowed down |1 |2 |3 |4 |5 |

|h. Sleep that is restless or disturbed |1 |2 |3 |4 |5 |

|i. Trembling |1 |2 |3 |4 |5 |

|j. Poor appetite |1 |2 |3 |4 |5 |

|k. Crying easily |1 |2 |3 |4 |5 |

|l. Feeling of being caught or trapped |1 |2 |3 |4 |5 |

|m. Suddenly being scared for no reason |1 |2 |3 |4 |5 |

|n. Blaming yourself for things |1 |2 |3 |4 |5 |

|o. Pains in the lower back |1 |2 |3 |4 |5 |

|p. Feeling lonely |1 |2 |3 |4 |5 |

|q. Feeling blue |1 |2 |3 |4 |5 |

|r. Worrying too much about things |1 |2 |3 |4 |5 |

|s. Feeling no interest in things |1 |2 |3 |4 |5 |

|t. Feeling fearful |1 |2 |3 |4 |5 |

|u. Heart pounding or racing |1 |2 |3 |4 |5 |

|v. Nausea or upset stomach |1 |2 |3 |4 |5 |

|w. Soreness of your muscles |1 |2 |3 |4 |5 |

|x. Trouble falling to sleep |1 |2 |3 |4 |5 |

|y. Difficulty making decisions |1 |2 |3 |4 |5 |

|z. Trouble getting your breath |1 |2 |3 |4 |5 |

|aa. Hot or cold spells |1 |2 |3 |4 |5 |

|bb. Numbness or tingling anywhere |1 |2 |3 |4 |5 |

|cc. A lump in your throat |1 |2 |3 |4 |5 |

|dd. Feeling hopeless about the future |1 |2 |3 |4 |5 |

|ee. Feeling weak in parts of your body |1 |2 |3 |4 |5 |

|ff. Feeling tense or keyed up |1 |2 |3 |4 |5 |

|gg. Heavy feelings in your arms or legs |1 |2 |3 |4 |5 |

|hh. Thoughts of death or dying |1 |2 |3 |4 |5 |

|ii. Overeating |1 |2 |3 |4 |5 |

|jj. Awakening in the early morning |1 |2 |3 |4 |5 |

|kk. Thoughts of ending your life |1 |2 |3 |4 |5 |

|ll. Feeling everything is an effort |1 |2 |3 |4 |5 |

|mm. Spells of terror or panic |1 |2 |3 |4 |5 |

|nn. Feeling so restless you couldn’t sit still |1 |2 |3 |4 |5 |

|oo. Feelings of worthlessness |1 |2 |3 |4 |5 |

|pp. The feeling that something bad is going to happen to you | | | | | |

| |1 |2 |3 |4 |5 |

|qq. Thoughts and images of a frightening nature |1 |2 |3 |4 |5 |

|rr. Feelings of guilt |1 |2 |3 |4 |5 |

|ss. The idea that something serious is wrong with your body | | | | | |

| |1 |2 |3 |4 |5 |

|tt. The idea that something is wrong with your mind | | | | | |

| |1 |2 |3 |4 |5 |

37. STRESS

a. How much stress have you experienced in the PAST MONTH as a result of:

| |None |A little |Some |A great deal |

|Home or family concerns |0 |1 |2 |3 |

|Work or school concerns |0 |1 |2 |3 |

|Financial concerns |0 |1 |2 |3 |

|Social or personal relationship |0 |1 |2 |3 |

|Health concerns |0 |1 |2 |3 |

|In general, how much stress have you experienced in the past | | | | |

|month? |0 |1 |2 |3 |

b. Have any of the following events happened to you in the LAST YEAR?

| |No |Yes |

|Change in residence |0 |1 |

|Change in marital status (marriage, divorce or separation) |0 |1 |

|Change in living arrangement |0 |1 |

|Gain or loss of employment |0 |1 |

|Retirement of self or spouse |0 |1 |

|Birth in the family |0 |1 |

|Death of a close friend or relative |0 |1 |

|Serious illness or injury of a close family member |0 |1 |

|Serious illness of injury of self |0 |1 |

|Major change in financial circumstances |0 |1 |

HAD Scale

Doctors are aware that emotions play an important part in illnesses and this questionnaire is designed to help your doctor know how you feel. Read each item and place a firm tick in the box opposite the reply, which comes closest to how you have been feeling in the past week.

Don’t take too long over your replies; your immediate reaction to each item will probably be more accurate than a long thought-out response.

Tick one box only in each section

|1 I feel tense or wound up: | |8 I feel as if I am slowed down: | |

|Most of the time |( |Nearly all the time |( |

|A lot of the time |( |Very often |( |

|Time to time, occasionally |( |Sometimes |( |

|Not at all |( |Not at all |( |

| | | | |

|2 I still enjoy the things I used to enjoy: | |9 I get a sort of frightened feeling like | |

|Definitely as much | |“butterflies” in the stomach: |( |

|Not quite so much |( |Not at all |( |

|Only a little |( |Occasionally |( |

|Hardly at all |( |Quite often |( |

| |( |Very often | |

|3 I get a sort of frightened feeling as if | | | |

|something awful is about to happen: | |10 I have lost interest in my appearance: |( |

|Very definitely and quite badly | |Definitely |( |

|Yes, but not too badly |( |I don’t take so much care as I should |( |

|A little, but it doesn’t worry me |( |I may not take quite as much care |( |

|Not at all |( |I take just as much care as ever | |

| |( | | |

|4 I can laugh and see the funny side of things: | |11 I feel restless as if I have to be on the move: | |

|As much as I always could | |Very much indeed |( |

|Not quite so much now | |Quite a lot |( |

|Definitely not so much now |( |Not very much |( |

|Not at all |( |Not at all |( |

| |( | | |

|5 Worrying thoughts go through my mind: |( |12 I look forward with enjoyment to things: |( |

|A great deal of the time | |As much as I ever did |( |

|A lot of the time | |Rather less than I used to |( |

|From time to time bur not too often | |Definitely less than I used to |( |

|Only occasionally |( |Hardly at all | |

| |( | | |

|6 I feel cheerful |( |13 I get sudden feelings of panic: |( |

|Not at all |( |Very often indeed |( |

|Not often | |Quite often |( |

|Sometimes | |Not very often |( |

|Most of the time |( |Not at all | |

| |( | | |

| |( |14 I can enjoy a good book or radio or TV programme:| |

|7 I can sit at ease and feel relaxed: |( |Often |( |

|Definitely | |Sometimes |( |

|Usually | |Not often |( |

|Not often | |Very seldom |( |

|Not at all |( | | |

| |( | | |

| |( | | |

| |( | | |

NAME: DATE:

Circle the word that describes how your pain feels right now:

Nil

Mild

Moderate

Severe

Most severe

Circle the words below that best describe your current pain.

Use only one word in each group.

Leave out any group if the words are unsuitable.

|1 |2 |3 |4 |

|Flickering |Jumping |Pricking |Sharp |

|Quivering |Flashing |Boring |Cutting Lacerating |

|Pulsing |Shooting |Drilling | |

|Throbbing | |Stabbing | |

|Beating | |Lancinating | |

|Pounding | | | |

|5 |6 |7 |8 |

|Pinching |Tugging |Hot |Tingling |

|Pressing |Pulling |Burning |Ithcy |

|Gnawing |Wrenching |Scalding |Smarting Stinging |

|Cramping | |Searing | |

|Crushing | | | |

|9 |10 |11 |12 |

|Dull |Tender |Tiring |Sickening |

|Sore |Taut |Exhausting |Suffocating |

|Hurting |Rasping | | |

|Aching |Splitting | | |

|Heavy | | | |

|13 |14 |15 |16 |

|Fearful |Punishing |Wretched |Annoying |

|Frightful |Gruelling |Blinding |Troublesome |

|Terrifying |Cruel | |Miserable |

| |Vicious | |Intense |

| |Killing | |Unbearable |

|17 |18 |19 |20 |

|Spreading |Tight |Cool |Nagging |

|Radiating |Numb |Cold |Nauseating |

|Penetrating |Drawing |Freezing |Agonizing |

|Piercing |Squeezing | |Dreadful |

| |Tearing | |Torturing |

SF36 Health Survey

INSTRUCTIONS: This set of questions asks for your views about your health.

This information will help keep track of how you feel and how well you are able to do your usual activities. Answer very question by marking the answer as indicated. If you are unsure about how to answer a uestion please give the best answer you can.

1. In general, would you say your health is: (Please tick one box.)

Excellent _

Very Good _

Good _

Fair _

Poor _

2. Compared to one year ago, how would you rate your health in general now? (Please tick one box.)

Much better than one year ago _

Somewhat better now than one year ago _

About the same as one year ago _

Somewhat worse now than one year ago _

Much worse now than one year ago _

3. The following questions are about activities you might do during a typical day. Does your health

now limit you in these activities? If so, how much? (Please circle one number on each line.)

Activities

Yes, Limited A Lot Limited A Little Not Limited At All

3(a) Vigorous activities, such as running, lifting heavy objects, participating in strenuous sports

Yes, Limited A Lot Limited A Little Not Limited At All

3(b) Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf

Yes, Limited A Lot Limited A Little Not Limited At All

3(c) Lifting or carrying groceries

Yes, Limited A Lot Limited A Little Not Limited At All

3(d) Climbing several flights of stairs

Yes, Limited A Lot Limited A Little Not Limited At All

3(e) Climbing one flight of stairs

Yes, Limited A Lot Limited A Little Not Limited At All

3(f) Bending, kneeling, or stooping

Yes, Limited A Lot Limited A Little Not Limited At All

3(g) Waling more than a mile

Yes, Limited A Lot Limited A Little Not Limited At All

3(h) Walking several blocks

Yes, Limited A Lot Limited A Little Not Limited At All

3(i) Walking one block

Yes, Limited A Lot Limited A Little Not Limited At All

3(j) Bathing or dressing yourself

Yes, Limited A Lot Limited A Little Not Limited At All

4. During the past 4 weeks, have you had any of the following problems with your work or other

regular daily activities as a result of your physical health? Yes No

4(b) Accomplished less than you would like Yes No

4(c) Were limited in the kind of work or other activities Yes No

4(d) Had difficulty performing the work or other activities (for example, it took

extra effort) Yes No

5. During the past 4 weeks, have you had any of the following problems with your work or other

regular daily activities as a result of any emotional problems (e.g. feeling depressed or anxious)?

Yes No

5(a) Cut down on the amount of time you spent on work or other activities Yes No

5(b) Accomplished less than you would like Yes No

5(c) Didn’t do work or other activities as carefully as usual Yes No

6. During the past 4 weeks, to what extent has your physical health or emotional problems interfered

with your normal social activities with family, friends, neighbours, or groups? (Please tick one box.)

Not at all _

Slightly _

Moderately _

Quite a bit _

Extremely _

7. How much physical pain have you had during the past 4 weeks? (Please tick one box.)

None _

Very mild _

Mild _

Moderate _

Severe _

Very Severe _

8. During the past 4 weeks, how much did pain interfere with your normal work (including both work

outside the home and housework)? (Please tick one box.)

Not at all _

A little bit _

Moderately _

Quite a bit _

Extremely _

9. These questions are about how you feel and how things have been with you during the past 4

weeks. Please give the one answer that is closest to the way you have been feeling for each item.

(Please circle one number on each line.)

1. All of the Time

2. Most of the Time A Good Bit of the Time

3. Some of the Time

4. A Little of the Time

5. None of the Time

9(a) Did you feel full of life? 1 2 3 4 5 6

9(b) Have you been a very nervous person? 1 2 3 4 5 6

9(c) Have you felt so down in the dumps that nothing could cheer you up? 1 2 3 4 5 6

9(d) Have you felt calm and peaceful? 1 2 3 4 5 6

9(e) Did you have a lot of energy? 1 2 3 4 5 6

9(f) Have you felt downhearted and blue? 1 2 3 4 5 6

9(g) Did you feel worn out? 1 2 3 4 5 6

9(h) Have you been a happy person? 1 2 3 4 5 6

9(i) Did you feel tired? 1 2 3 4 5 6

10. During the past 4 weeks, how much of the time has your physical health or emotional problems

interfered with your social activities (like visiting with friends, relatives etc.) (Please tick one box.)

All of the time _

Most of the time _

Some of the time _

A little of the time _

None of the time _

11. How TRUE or FALSE is each of the following statements for you?

(Please circle one number on each line.) Definitely

True Mostly True Don’t Know Mostly False DefinitelyFalse

11(a) I seem to get sick a little easier than other people 1 2345

11(b) I am as healthy as anybody I know 1 2 3 4 5

11(c) I expect my health to get worse 1 2 3 4 5

11(d) My health is excellent 1 2 3 4 5

Thank You!

On the next 3 pages we would like you to tell us how often you have had problems with your mouth, teeth or gums in the last 3 months.

Never Hardly ever Occasionally Fairly often Very often

1. Have you had trouble pronouncing any words because of problems with your teeth, mouth or dentures? ( ( ( ( (

2. Have you felt that your sense of taste worsened because of problems with your teeth, mouth or dentures? ( ( ( ( (

3. Have you had painful aching in your mouth? ( ( ( ( (

4. Have you found it uncomfortable to eat any foods because of problems with your teeth, mouth or dentures? ( ( ( ( (

5. Have you been self conscious because of problems with your teeth, mouth or dentures? ( ( ( ( (

6. Have you felt tense because of problems with your teeth, mouth or dentures? ( ( ( ( (

7. Has your diet been unsatisfactory because of problems with your teeth, mouth or dentures? ( ( ( ( (

8. Have you had to interrupt meals because of problems with your teeth, mouth or dentures? ( ( ( ( (

9. Have you found it difficult to relax because of problems with your teeth, mouth or dentures? ( ( ( ( (

10. Have you been a bit embarrassed because of problems with your teeth, mouth or dentures? ( ( ( ( (

11. Have you been irritable with other people because of problems with your teeth, mouth or dentures? ( ( ( ( (

12. Have you had difficulty doing your usual jobs because of problems with your teeth, mouth or dentures? ( ( ( ( (

13. Have you felt that life in general was less satisfying because of problems with your teeth, mouth or dentures?( ( ( ( (

14. Have you been totally unable to function because of problems with your teeth, mouth or dentures? ( ( ( ( (

1. Do you have altered sensation on the affected side of your lip? ( ( ( ( (

2. What type of sensation do you get on the affected side of your lip?

numbness ( ( ( ( (

tingling ( ( ( ( (

more sensitive ( ( ( ( (

discomfort ( ( ( ( (

pain ( ( ( ( (

other describe ( ( ( ( (

3. What causes these pain sensations in your lip?

eating ( ( ( ( (

touching the affected area ( ( ( ( (

speaking ( ( ( ( (

temperature change ( ( ( ( (

brushing teeth ( ( ( ( (

just spontaneous ( ( ( ( (

other comment

4. How bad is the pain?

This is a way of recording your pain. A mark at the no pain end of the line means you are completely free of pain. Marks along the line means gradually worse pain, until you get to the other end where your pain is unbearable. Please could you put a mark through the line at the place appropriate for your pain now.

( (

No pain Unbearable pain

Never Hardly ever Occasionally Fairly often Very often

4. What causes these tingling sensations in your lip?

eating ( ( ( ( (

touching the affected area ( ( ( ( (

speaking ( ( ( ( (

temperature change ( ( ( ( (

brushing teeth ( ( ( ( (

just spontaneous ( ( ( ( (

other comment

5. What causes these sensations of discomfort in your lip?

eating ( ( ( ( (

touching the affected area ( ( ( ( (

speaking ( ( ( ( (

temperature change ( ( ( ( (

brushing teeth ( ( ( ( (

just spontaneous ( ( ( ( (

other comment

6. Do you bite or burn the affected side of your lip? ( ( ( ( (

7. If you are a man, is your shaving affected by the changed sensation of your lip? ( ( ( ( (

8. Do you have problems with dribbling due to the changed sensation of your lip? ( ( ( ( (

9. Is your speech affected by the changed sensation of your lip? ( ( ( ( (

10. Is your kissing affected by the changed sensation in your lip? ( ( ( ( (

11. Any other comment?

Tick only positive ones

|Provoking |Factor |Relieving |

| |Talking | |

| |Eating | |

| |Brushing teeth | |

| |Shaving/washing | |

| |Brushing hair/touching temples | |

| |Cold/wind | |

| |Warmth | |

| |Foods cold or hot | |

| |Pressure on teeth/biting | |

| |Opening wide | |

| |Stooping/bending | |

| |Stress/tension/relaxing | |

| |Sleep/rest | |

| |Lying down | |

| |Fatigue | |

| |Distraction | |

| |Working | |

| |Alcohol | |

| |Other please specify | |

Associated factors: tick if present

|Presence |Factor |Presence |Factor |

| |Altered/poor taste | |Clicking joint |

| |Disturbed salivation | |Bruxism |

| |Altered sensation/numbness | |Cheek clenching |

| |Sleep disturbance | |Unable to open wide |

| |Waking due to pain | |Ringing in the ears |

| |Colour change tissues/redness | |Deafness |

| |Swelling of face | |Headaches |

| |Nasal stuffiness/post nasal drip | |Dizziness |

| |Double or blurred vision | |Migraine with or without aura |

| |Excessive tearing of eyes | |Neck pain |

| |Excessive dryness of eyes | |Back pain |

| |Visual disturbances | |Irritable bowel |

| |Eye redness | |Nausea |

| |Fatigue/loss strength | |Abdominal pain/menstrual |

| |Stiffness of joints | |Impaired concentration |

| |Reduced appetite | |Other please specify |

| | | | |

PAST TREATMENTS:

|Drugs |Daily Dosage/ time used |Side effects |Efficacy |

| | | | |

| | | | |

| | | | |

| | | | |

Previous surgery

Other treatments: splints dental-cons endodontics, extraction,

Alternative medicine, acupuncture/low intensity laser/TENS/homeopathy

Previous consultations/number: GP dentist oral surgeon neurologist psychiatrist

ENT surgeon neurosurgeon psychologist pain specialist counsellor other

EFFECT OF PAIN AND COPING:

Effect of pain on quality of life: none mild moderate considerable

What changes have occurred in your life as a result of the pain:

Have you taken time off work: No/Yes how much:

How do people respond to your pain/is it helpful:

Do you feel anxious: no yes

In the last month have you felt a lack of pleasure in life: no yes

In the last month have you felt depressed: no yes

Do you have: feeling of worthlessness/guilt/disturbed sleep/early am wakening/ appetite changes

What do you think has caused the pain and what do you think I can do:

Timing/Pattern of pain

Refractory period of no pain observed after a paroxysm of pain for few minutes

Refractory period of no pain observed after a mixture of sharp shooting and dull

(burning) pain

Continuous (persistent) dull aching pain in between each sharp attack

[pic]

Continuous low-grade dull aching or burning pain

-----------------------

pain free

period

paroxysmal

pain

Sharp ,shooting

Sharp,

shooting

dull, burning

burning

refractory

pain free

period

Dull pain

aching aching

background

sharp

shooting

pain

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

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