Download Head, Neck, TMJ - david l. way orthodontics

David L. Way, D.D.S., M.S.
HEAD-NECK & TMJ HISTORY
Please help us understand your problem by checking the following information; please be specific (Circle
the words right, left, yes, or no.):
Disc History:
Have you heard popping sounds in your ear(s)?
Has the popping stopped?
Has the size of your jaw opening decreased?
Do you hear clicking sounds in your ear(s)?
Do you hear grinding sounds in your ear(s)?
Do you have pain in your ear(s)?
right / left _________________
right / left__________________
right / left__________________
right / left _________________
right / left _________________
right / left _________________
Muscle History:
Is your jaw opening limited?
Is your opening limitation most in the morning?
Do you wake up with facial pain?
Do you have pain below your ear(s)?
Do you have pain in your temples?
Do you clench or grind your teeth?
Do you have lower neck aches or backaches?
Are you in an emotional period of your life?
yes / no___________________
yes / no___________________
yes / no ___________________
yes / no ___________________
yes / no ___________________
yes / no ___________________
yes / no ___________________
yes / no ___________________
Joint Change History:
Has your bite changed?
Has your chin moved backwards?
Do your teeth hit unevenly?
Have you had jaw surgery or orthodontic treatment?
Do you clench or grind your teeth?
Have you heard popping sounds in your ear(s)?
Have you had an injury to your face, head, neck or jaw?
Are you a female?
Are you between 12 and 17 years old?
Are your arms, legs, feet, hands or finger joints painful swollen or stiff?
Are you or have you taken corticosteroids?
Do you or have you had hyperparathyroidism?
yes / no ___________________
yes / no ___________________
yes / no ___________________
yes / no ___________________
yes / no ___________________
yes / no ___________________
yes / no ___________________
yes / no ___________________
yes / no ___________________
yes / no ___________________
yes / no ___________________
yes / no ___________________
Obstructive Sleep Apnea History:
Do you fall asleep during the day?
Have you fallen asleep while driving?
Do you have disrupted sleep?
Do you urinate frequently during the night?
Do you snore heavily at night?
Do you talk in your sleep?
Do you suffer from daytime fatigue?
Do you experience daytime sleepiness?
Have you had a recent weight gain?
yes / no ___________________
yes / no ___________________
yes / no ___________________
yes / no ___________________
yes / no ___________________
yes / no ___________________
yes / no ___________________
yes / no ___________________
yes / no ___________________
Do you have high blood pressure?
Do you take blood pressure medication?
Do you have an irregular heartbeat?
Do you suffer from depression?
Do you have headaches when you wake up?
Does your spouse see you stop breathing during sleep?
Do you drink alcoholic beverages?
Do you take sedative type medication?
yes / no__________________
yes / no __________________
yes / no __________________
yes / no __________________
yes / no __________________
yes / no __________________
yes / no __________________
yes / no __________________
Chronology:
When did you first notice the above symptoms?
Date:____________________
Have the above symptoms increased with time?
Do you attribute the symptoms to one incident?
yes / no___________________
yes / no___________________
How do you control your head and neck symptoms? ‫ٱ‬cold / heat packs ‫ٱ‬physical therapy
‫ٱ‬diet change
‫ٱ‬anti-inflammatory
‫ٱ‬pain medication ‫ٱ‬limited jaw movement
‫ٱ‬injections-joint/mm
‫ٱ‬other__________________________________________________________
Have you had treatment for your-head and neck symptoms?
‫ٱ‬physical therapy
‫ٱ‬TMJ specialist
‫ٱ‬pain clinic
‫ٱ‬oral surgeon
‫ٱ‬orthodontist
‫ٱ‬general dentist
‫ٱ‬ENT
‫ٱ‬neurologist
‫ٱ‬splint
‫ٱ‬TMJ surgery
‫ٱ‬occlusal reconstruction ‫ٱ‬orthodontic care ‫ٱ‬equilibration
‫ٱ‬physical therapy
‫ٱ‬jaw surgery
‫ٱ‬other____________________________________
How do you control your sleep apnea?
‫ٱ‬restrict alcohol beverages
‫ٱ‬restrict sedative medication
‫ٱ‬sleep upright
‫ٱ‬sleep on side
‫ٱ‬sleep on back
‫ٱ‬sleep with special pillow position
Have you had treatment for sleep apnea?
‫ٱ‬weight loss
‫ٱ‬c-pap
‫ٱ‬dental appliance
‫ٱ‬soft palate surgery
‫ٱ‬nasal surgery
‫ٱ‬other_______________________________________________________________________________
Name:______________________________________________ Date:____________________________
Modified from 1999 Arnett Facial Reconstruction Courses, Inc.
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