Download Oral and Maxillofacial Surgery Associates, P

Oral and Maxillofacial Surgery Associates, P.A.
______________________________________________
2320 Cosgrove Avenue, Charleston,
Dr. SC
Lon29405
R. Doles
2320 Cosgrove Avenue
Charleston, SC 29405
Tel:(843) 554-5003 Fax:(843) 745-0003
Email – [email protected]
TEMPOROMANDIBULAR
TEMPOROMANDIBULARJOINT
JOINTEVALUATION
EVALUATION
CONFIDENTIAL INFORMATION
DATE:_______________________________
PATIENT NAME: _____________________________________________
NATURE OF PROBLEM:
________________________________________________________________________
________________________________________________________________________
DATE OF ONSET: ____________
DID SYMPTOMS FOLLOW ANY PHYSICAL INJURY OR EMOTIONAL
OCCURRENCE? PLEASE DESCRIBE IN DETAIL:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
CHECK SPECIALIST(S) YOU HAVE CONSULTED FOR THIS PROBLEM:
( ) General Physician
( ) Chiropractor
( ) ENT
( ) Neurologist
( ) Clinic
( ) Psychiatrist
( ) Psychologist
( ) Physical Therapist
( ) Dentist
( ) Oral Surgeon
( ) Orthodontist
( ) Periodontist
LIST MEDICATIONS YOU ARE CURRENTLY TAKING FOR THIS
CONDITION: ___________________________________________________________
LIST TREATMENT YOU HAVE RECEIVED FOR THIS CONDITION: ________
________________________________________________________________________
WHICH TREATMENT HAS PROVEN MOST SUCCESSFUL TO DATE:
________________________________________________________________________
________________________________________________________________
PLEASE DESCRIBE WHAT AGGRAVATES YOUR CONDITION:
________________________________________________________________________
________________________________________________________________________
WHAT EFFECTIVELY RELIEVES YOUR PAIN?
________________________________________________________________________
________________________________________________________________________
DOES YOUR PAIN INTERFERE WITH YOUR DAILY ROUTINE? IF YES,
PLEASE DESCRIBE:
________________________________________________________________________
________________________________________________________________________
ON A SCALE OF 1 TO 10 (10 being greatest), PLEASE INDICATE THE
NUMBER THAT BEST DESCRIBES THE SEVERITY OF YOUR PAIN.
________________
SYMPTOMS:
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
TENSION HEADACHES
DIAGNOSED MIGRAINE HEADACHES
DEPRESSION
DIFFICULTY IN SWALLOWING OR CHEWING NORMAL DIET
PAINFUL MOUTH
SORENESS OF FACE OR NECK AREAS
STIFF NECK
GRINDING OF TEETH
CLENCHING OF TEETH
GRINDING OR CLENCHING WHILE SLEEPING
POPPING OR GRINDING SOUNDS IN THE JAW AREA
DIFFICULTY OPENING MOUTH WIDELY
DIFFICULTY IN CLOSING YOUR MOUTH NORMALLY
CHANGE IN YOUR OCCLUSION (BITE)
STIFFNESS OF JAW UPON AWAKENING
SORE TEETH UPON AWAKENING
SLEEP DISTURBANCES OR PROBLEMS
ARTHRITIS OR PROBLEMS WITH OTHER JOINTS
HISTORY OF ORTHODONTIC TREATMENT
HISTORY OF TMJ INJURY, TREATMENT OR SURGERY
SIGNATURE: _________________________________________
(PATIENT/ PARENT / GUARDIAN)
DATE: _________________