USE
Medical History Questionnaire OFFICE
Patient ID:_____
NAME:
FORM DATE:
____/____/_______
____________________ __ ____________________ DATE OF BIRTH: ___/___/______
Allergens
No known allergens
Iodine
Plastic
Antibiotics
Latex
Sedatives
Aspirin
Local anesthetics
Sleeping pills
Barbiturates
Metals
Sulfa drugs
Codeine
Penicillin
Other: ____________________
____________________
Current Medications
Medicine
Dosage/Frequency
Reason
____________________ ____________________ _________________________
____________________ ____________________ _________________________
____________________ ____________________ _________________________
____________________ ____________________ _________________________
____________________ ____________________ _________________________
Other
Medical History
Significant
Current
Significant
Current
Date / Note
Date / Note
Medical Condition Never Past
Medical Condition Never Past
Acid reflux
__________
Bruising easily
__________
Anemia
__________
Cancer
__________
Atherosclerosis
__________
Chemotherapy
__________
Arthritis
__________
Chronic fatigue
__________
Asthma
__________
Chronic pain
__________
Autoimmune disorder
__________
COPD
__________
Bleeding easily
__________
Coronary heart disease
__________
Blood pressure - High
__________
Current pregnancy
__________
Blood pressure - Low
__________
Depression
__________
Medical History
Significant
Medical Condition
Current
Significant
Current
Date / Note
Date / Note
Never Past
Medical Condition Never Past
Diabetes
__________
Mood disorder
__________
Difficulty sleeping
__________
Multiple sclerosis
__________
Dizziness
__________
Muscular dystrophy
__________
Emphysema
__________
Nasal allergies
__________
Epilepsy
__________
Neuralgia
__________
Fibromyalgia
__________
Osteoarthritis
__________
Glaucoma
__________
Osteoporosis
__________
Gout
__________
Parkinson's disease
__________
Heart attack
__________
Prior orthodontic
treatment
__________
Heart murmur
__________
Psychiatric care
__________
Heart pacemaker
__________
Radiation treatment
__________
Heart valve replacement
__________
Rheumatic fever
__________
Hemophilia
__________
Rheumatoid arthritis
__________
Hepatitis
__________
Sinus problems
__________
Hypertension
__________
Sleep apnea
__________
Hypoglycemia
__________
Stroke
__________
Immune system disorder
__________
Tendency for ear
infections
__________
Ischemic heart disease
(reduced blood supply)
__________
Thyroid disorder
__________
Kidney problems
__________
Tuberculosis
__________
Liver disease
__________
Tumors
__________
Meniere's disease
__________
Urinary disorders
__________
Mitral valve prolapse
__________
Other
Medical Condition Current Past Date / Note
Medical Condition Current Past Date / Note
____________________
____________________
__________
__________
Family History
Has any member of your family (parent, sibling, or grandparent) had:
Cancer
Diabetes
Stroke
Heart disease
High blood pressure
Sleep disorder
Obesity
Father snores
Father has sleep apnea
Thyroid disorder
Mother snores
Mother has sleep apnea
Social History
Patient's
Occupation
______________________________ Employer ______________________________
Tobacco Use: Cigarettes
Never smoked
Current smoker
# of packs per
____
day
# of years
Other tobacco:
Alcohol Use: Do you drink alcohol?
Caffeine Intake:
None
Yes
Coffee/Tea/Soda
Pipe
No
Cigar
Snuff
____
Quit
When did you quit?
________________
Chew
If yes, # of drinks per week: ____
# of cups per day: ____
Additional:
Regular exercise
Patient Signature
I authorize the release of a full report of examination findings, diagnosis, treatment program etc., to any
referring or treating dentist or physician. I additionally authorize the release of any medical information to
insurance companies or for legal documentation to process claims. I understand that I am responsible for all
charges for treatment to me regardless of insurance coverage.
Patient Signature:
Date:
__________________________________________________
____________________
I certify that the medical history information is complete and accurate.
Patient Signature:
__________________________________________________
Date:
____________________
Review of Systems
NAME:
FORM DATE:
OFFICE USE
Patient ID:_____
____/____/_______
____________________ __ ____________________ DATE OF BIRTH: ___/___/______
General
Within Normal Limits
Reported
Denied Appetite changes
Reported
Denied Sensitivity to heat or cold
Reported
Denied Marked weight change
Reported
Denied Tires easily
Reported
Denied Night sweating
Reported
Denied Unusual weakness
Reported
Denied ____________________
Reported
Other
Reported
Denied Recent trauma or infection
Denied ____________________
Head, Eyes, Ears, Nose and Throat
Within Normal Limits
Reported
Denied Dizziness
Reported
Denied Sore throat or hoarseness
Reported
Denied Headaches
Reported
Denied Swallowing difficulties
Reported
Denied Nose bleeding
Reported
Denied Trauma
Reported
Denied Ringing in ears
Reported
Denied Ulcers or lumps in mouth
Reported
Denied Sinus infections
Reported
Denied ____________________
Reported
Other
Reported
Denied Sore gums or tongue
Denied ____________________
Lungs
Within Normal Limits
Reported
Denied Persistent cough
Reported
Denied Shortness of breath
Reported
Other
Denied Swelling of ankles
Reported
Denied ____________________
Reported
Denied Wheezing
Reported
Denied ____________________
Heart
Reported
Other
Reported
Within Normal Limits
Denied High blood pressure
Denied ____________________
Reported
Denied ____________________
Neurologic
Reported
Reported
Other
Reported
Within Normal Limits
Denied Dizziness
Denied Headaches
Reported
Denied ____________________
Denied Muscle weakness or paralysis
Reported
Reproductive
Reported
Reported
Other
Reported
Denied ____________________
Within Normal Limits
Denied Impotence
Denied Lack of sex drive
Denied ____________________
Reported
Denied ____________________
Other
Within Normal Limits
Other
Reported
Denied ____________________
Reported
Denied ____________________
Patient Signature
I authorize the release of a full report of examination findings, diagnosis, treatment program etc., to any
referring or treating dentist or physician. I additionally authorize the release of any medical information
to insurance companies or for legal documentation to process claims. I understand that I am responsible
for all charges for treatment to me regardless of insurance coverage.
Patient Signature:
Date:
__________________________________________________
____________________
I certify that the medical history information is complete and accurate.
Patient Signature:
__________________________________________________
Date:
____________________
Version:
TMDQUES1
NAME:
Head, Neck and Facial Pain
Questionnaire
____________________ __ ____________________
DATE OF BIRTH: ___/___/______
OFFICE USE
Patient ID:_____
CURRENT DATE: ____/____/_______
MALE
FEMALE
Contact ID:
____________________
Referring Physician:
______________________________
Number
Frequency Intensity Number
Frequency Intensity
#1 = the most severe symptom
1-4
1-10 #1 = the most severe symptom
1-4
1-10
__ Jaw pain
__ Morning head pain
__ Jaw clicking
__ Ringing in the ears
__ Jaw locking
__ Dizziness
__ Limited mouth opening
__ Nocturnal teeth grinding
__ Facial pain
__ Frequent Heavy Snoring
__ Neck pain
__ Pain when chewing
__ Headaches
__ Migraines
Other: Write In
____________________ ____________________
Symptoms
HEAD PAIN
Unsupported Control
Unsupported Control
Unsupported Control
Unsupported Control
Unsupported Control
JAW PAIN
Jaw pain - on opening
Jaw pain - while chewing
Jaw pain - at rest
JAW SYMPTOMS
Jaw popping
Jaw clicking
Jaw locks closed
Jaw locks open
Teeth grinding
MOUTH AND NOSE RELATED CONDITION
Symptoms
MOUTH AND NOSE RELATED CONDITION
THROAT, NECK & BACK RELATED
CONDITIONS CONTINUED
Burning tongue
Frequent biting of cheek
Back pain - lower
Frequent snoring
Back pain - middle
Broken teeth
Back pain - upper
Teeth clenching
Chronic sore throat
Dry mouth
Constant feeling of a foreign object in throat
EAR RELATED CONDITIONS
Difficulty in swallowing
Buzzing in the ears
Limited movement of neck
Tinnitus (ringing in the ears)
Neck pain
Ear pain
Numbness in the hands or fingers
Ear congestion
Sciatica
Pain in front of the ear
Scoliosis
Hearing loss
Shoulder pain
Recurrent ear infections
Shoulder stiffness
Pain behind the ear
Swelling in the neck
Swollen glands
EYE RELATED CONDITIONS
Thyroid enlargement
Blurred vision
Tightness in throat
Eye pain
Tingling in the hands or fingers
Pain or pressure behind the eyes
Chronic sinusitis
Other ____________________
____________________
History Of Symptoms
Is there
If you have received
anything
treatment/diagnosis
that makes
_____________________________ in the past, where
____________________________
your pain or
was services
discomfort
received?
worse?
Is there
anything
that makes _____________________________
your pain or
discomfort
Yes
No
Are you currently being treated for TMD?
better?
What other
information
is important
If being treated
_____________________________
regarding
where are you
the pain or
receiving
condition?
treatment?
______________________________
Have you been treated/diagnosed for TMD
before?
Yes No
Other ____________________
____________________
History Of Treatment
Practitioner's Name
______________________
Specialty
Treatment
Approximate
Date
____________ __________________________________ ______________
_______________________ _____________ __________________________________ ______________
_______________________ _____________ __________________________________ ______________
_______________________ _____________ __________________________________ ______________
History Of Accident
COMPLETE THIS SECTION IF YOU WERE INVOLVED IN AN ACCIDENT OR A TRAUMATIC
INCIDENT RELATED TO THE CURRENT VISIT:
DATE OF ACCIDENT OR INCIDENT:
Enter date (month/day/year) ______________________________
THE PATIENT BELIEVES THE CAUSE OF
THE PAIN OR CONDITION TO BE:
Select one:
Hit by an object
A motor vehicle accident
Hit an object
A motorcycle accident
An illness
A work related incident
An injury
A playground incident
Orthodontics
An athletic endeavor
Dental procedures
A fight
Whiplash
A fall
Other: ______________________________
An accident
History Of Accident
COMPLETE THIS SECTION IF YOU WERE INVOLVED IN AN ACCIDENT OR A TRAUMATIC
INCIDENT RELATED TO THE CURRENT VISIT:
HISTORY OF ACCIDENT
WERE YOU:
Select one:
Did you fall?
A passenger in a motor vehicle
Were you hit by an object?
The driver of a vehicle
Did you hit an object?
Other: ______________________________
A pedestrian
At work
IF IN A VEHICLE, WHERE WAS THE VEHICLE
HIT?
At the front end
Head on
At the rear end
On driver's side
At the front right area
On passenger's side
Other
area:
At the front leftt area
______________________________
At the rear right area
At the rear left area
INDICATE IF THERE WAS ANY TRAUMA:
The patient's:
Forehead
Top of head
Face
Teeth
Chin
Jaw
Side of head Other: ______________________________
Back of head
Forcibly struck the:
Steering wheel
Headreast
Windshield
Seat
Passenger's side window
Roof
Driver's side window
Interior of the car
Passenger's side door
Other: ______________________________
Driver's side door
Head Pain History
Pain Qualities
--- LOCATION --both sides
the left side
Which side are the
headaches worse?
the right side
____________________
Head Pain History
Pain Qualities
--- LOCATION ---
the temple
the back of the head
Headache spreads to
the temple
the back of the head
the forehead
____
Headaches on a 0-10 Pain Scale
____
Neck Pain on a Numeric Pain Scale
____
Facial Pain on a 0-10 Pain Scale
occasional (0-3/mo)
FREQUENCY
frequent (3-6/mo)
constant
____________________
____________________
--- DURATION --Seconds
--- SEVERITY ON A SCALE OF 0-10 ----- 0=No Pain 10=Worst Pain Imaginable --____
Jaw Pain on a Numeric Pain Scale
Minutes
Hours
Days
Weeks
When having pain do you
experience:
Dizziness
Sensitivity to noise
Double vision
Throbbing
Fatigue
Vomiting
Nausea
Burning
Sensitivity to light (photophobia)
Other ____________________
____________________
DRAW YOUR PAIN PATTERNS FOLLOWING
THIS KEY
Enter any text to appear below the image: ________________________________________
Patient Signature
I authorize the release of a full report of examination findings, diagnosis, treatment program etc., to any
referring or treating dentist or physician. I additionally authorize the release of any medical information to
insurance companies or for legal documentation to process claims. I understand that I am responsible for all
charges for treatment to me regardless of insurance coverage.
Patient Signature:
__________________________________________________
I certify that the medical history information is complete and accurate.
Patient Signature:
__________________________________________________
Date:
____________________
Date:
____________________