Download 11-28-13 Head Neck and Facial Pain Questionnaire

HEAD, NECK AND FACIAL PAIN QUESTIONNAIRE This questionnaire is a detailed, comprehensive health history provided by you in order for our team to effectively and efficiently reach a diagnosis and determine the source(s) of the reason you are visiting our facility. Please take your time and answer each question as completely as possible. Your information is confidential and only released to other medical facilities upon your written permission. Date: __________________________________________ Name: Birthdate: Address: City, State, Zip: If patient is a minor, parent or guardian name: Home Ph: Social Security#: Emergency Contact: Age: Work Phone: Cell: E-­‐Mail: Emergency Phone: WHAT ARE THE CHIEF COMPLAINTS FOR WHICH YOU ARE SEEKING TREATMENT? Please number your complaints: #1 being the most important, #2 the next important, etc. Then, rate your complaints for frequency and intensity: Frequency: (1-­‐Seldom, 2-­‐Occassional, 3-­‐Frequent, 4-­‐Every Day) Intensity: (0 is No Pain and 10 is Most Severe Pain) Number Frequency Back Pain Dizziness Ear Congestion Ear Pain Eye Pain Facial Pain Fatigue Headaches Jaw Clicking Jaw Joint Noises Jaw Locking Jaw Pain Limited Mouth Opening Muscle Soreness Muscle Twitching Neck Pain Pain when Chewing Ringing in the Ears Shoulder Pain Sinus Congestion Throat Pain Visual Disturbances Other: Intensity On a 0-­‐10 scale (0 being no effect and 10 being unable to perform), please tell us to what degree your symptoms interfere with your daily living activities (sleeping, working, leisure activities, eating, etc): ___________ Patient Name: (Last, First, M) Birth Date: Sex:  M  F MEDICAL HISTORY FORM HOSPITALIZATIONS OR SURGERIES (Recent and Past) Date Reason for Procedure Name and Address of Facility MAJOR ILLNESSES OR SPECIAL MEDICAL OR PSYCHOLOGICAL PROBLEMS (Current and Past) Date Reason for Procedure Name and Address of Facility CURRENT MEDICATIONS FOR ALL HEALTH ISSUES (include Vitamins and Over-­‐the-­‐Counter) Dosage Times Medication Name per Day per Day Reason Length of Time Taken Patient Name: (Last, First, M) Birth Date: Sex:  M  F PAST MEDICATIONS NO LONGER TAKEN (include Vitamins and Over-­‐the-­‐Counter) Dosage Times Medication Name per Day per Day Reason Length of Time Taken ALLERGIES Y  N  Antibiotics Y  N  Metals Other Allergens: Y  N  Aspirin Y  N  Penicillin Y  N  Codeine Y  N  Plastic Y  N  Iodine Y  N  Sedatives Y  N  Latex Y  N  Sleeping Pills Y  N  Local Anesthetics Y  N  Sulfa Drugs When did your condition first occur? ___________________________________________________________ What do you believe to be the cause of your pain or condition? __________________________________________________________________________________________
__________________________________________________________________________________________ What other information is pertinent to your pain or condition? _____________________________________ __________________________________________________________________________________________ Patient Name: (Last, First, M) Birth Date: Sex:  M  F HEALTH PROBLEMS: PLEASE CHECK ALL HEALTH PROBLEMS (Current and Past) Cardiovascular Rheumatic fever/heart disease Heart murmur Mitral valve prolapse Artificial heart valve Infective endocarditis High blood pressure High cholesterol Angina Heart attack Congenital heart defect or lesion Heart surgery/angioplasty Pacemaker/defibrillator Stroke Vascular disease or surgery Aneurysm Racing heart (palpitations) Chest pain Swollen feet/ankles Other heart problems Respiratory Asthma Bronchitis/Pneumonia Emphysema Allergic/Immunologic Hay Fever Anaphylactic shock reaction Reaction to foods: Type of foods: ______________________ Reaction to local anesthetic (novacaine) Reaction to penicillin, other antibiotics Reaction to sulfa drugs Reaction to sedatives, or sleeping pills Reaction to barbiturates Reaction to aspirin or other pain medication Reaction to iodine Reactions to other medications: Please list: Yes                                    Infectious Disease Sexually transmitted disease HIV positive Hepatitis: Type ______ Tuberculosis (TB) Other current infection disease Genitor-­‐Urinary Bladder problems/infections Kidney disease Urinary retention or difficulty urinating Blood in urine Hematologic/Lymphatics Blood transfusion Anemia Hemophilia/other bleeding disorder Leukemia Sickle Cell Anemia Disease Tumor or cancer Chemotherapy Radiation therapy Bleed for extended amounts of time Bruise easily Swollen glands Eyes Glaucoma Full or partial blindness Double vision Blind spots Blurred vision Women Are you taking contraceptives Are you pregnant Are you nursing presently Had a hysterectomy or ovariectomy Are you on hormone replacement therapy Dysmenorrhea (painful menstrual periods) Breast Cancer Premenstrual Syndrome (PMS) Yes                                  Patient Name: (Last, First, M) Birth Date: Sex:  M  F HEALTH PROBLEMS: PLEASE CHECK ALL HEALTH PROBLEMS (Current and Past) cont… Gastrointestinal Stomach/intestinal ulcers Gastric reflux Colitis Liver disease/jaundice Gallbladder stones Persistent diarrhea Persistent constipation Bloody or black stools Skin/Integumentary Allergy to latex (rubber) Psoriasis (chronic skin rash) Endocrine Diabetes Thyroid disease Pancreatic disease Neurologic Multiple sclerosis (MS) Epilepsy, seizures or convulsions Migraine Muscular dystrophy Cerebral Palsy Parkinson’s disease Severe headaches Yes                     Wake up from headache Fainting, dizzy spells or black-­‐outs Speech difficulty/slurring Facial weakness/dropping Facial twitching Tingling or numbness in face Tingling or numbness in arms/fingers Memory loss Balance problem Weakness in parts of body Musculoskeletal/Rheumatic Fibromyalgia            Chronic fatigue syndrome  Ear, Nose, Throat Sinusitis or sinus headache Nasal rhinitis Inner ear infections Tinnitus/ringing in ear(s) Frequent nasal congestion Vertigo (head spinning) Hearing difficulty/loss Plugged ears Mental Health Depression Anxiety disorder Mental health treatment Physical or sexual abuse Eating disorder Stressed out/overwhelmed Low energy level Crying spells Sleep problems/insomnia Poor concentration Trouble relaxing Felt like taking your own life in the past 6 months Do you feel your heart racing Do you often feel depressed Do you frequently feel angry Do you feel your mood or personality changed recently Other (please list) Chemical Use Coffee daily Beer or wine daily Tea daily Cocktails or other alcoholic beverages daily Soft drinks (pop) daily Chewing tobacco Smoke tobacco Cocaine or other stimulants Drug/alcohol dependency (current/recovering) Take alcohol or recreational drugs to help with pain Immediate family members chemically dependent Yes                                     Patient Name: (Last, First, M) Birth Date: Sex:  M  F HEALTH PROBLEMS: PLEASE CHECK ALL HEALTH PROBLEMS (Current and Past) cont… Musculoskeletal/Rheumatic cont… Osteoarthritis Osteoporosis Rheumatoid arthritis Artificial joint (knee/hip/other) Swollen or painful joints Hand/wrist pain/carpel tunnel Low back pain Neck pain Shoulder and upper back pain Yes          DENTAL and OROFACIAL HISTORY Have you had any of the following dental treatments or problems? Orthodontic braces Orthognatic or bite surgery Wisdom teeth extracted Other extracted teeth Bite adjusted Splint or bite guard Upper full denture Lower full denture Mouth biopsy Missing teeth need replacement Need new crown(s) or filling(s) Tooth wear or fracture Persistent tooth pain Tooth or teeth sensitive to hot/cold Painful tooth when biting on it Difficulty chewing due to bite Unstable bite Bite that is changing Cross bite Open bite Yes                     TMJ Jaw joint clicking or popping noise Jaw joint grating or crepitus noise Jaw locking or getting stuck open Jaw locking closed/cannot open all the way Mouth Lesions or Disease Burning or painful tongue Dry mouth Mouth sores Tongue sores Fever blisters/Cold sores on lips Lumps or bumps in mouth Swelling in mouth Mouth ulcers or canker sores Colored or discolored areas in mouth Yes              Patient Name: (Last, First, M) Birth Date: Sex:  M  F ORAL HABITS Have you or others noticed yourself doing any of the following oral habits regularly (more than once a week) Chewing on one side Leaning on the jaw Grinding teeth at night Grinding your teeth when awake Waking up with sore jaws Clenching your teeth when awake Clenching your teeth at night Holding your jaw forward Chewing gum Playing a musical instrument with the mouth Sleeping on stomach Touching or holding your teeth together Holding or pressing the tongue against your teeth Holding your jaw in a rigid or tense position Biting objects (pens, tooth picks, etc) Biting your cheeks Biting your nails or cuticles Biting your lips Biting your tongue Bracing the phone with shoulder or jaw Mouth or Facial Injury Have you had trauma or injury to your jaw, head or neck? Describe: Yes                      Have you or will you consult an attorney about this condition? Describe:  Comments: Periodontal (Gums) Periodontal disease Gingivitis or bleeding gums Loose teeth Deep pockets in gums Sore gums Impacted or un-­‐erupted teeth Oral Obstructive Sleep/Breathing Problems Snore loudly or have sleep apnea Stop breathing while sleeping Choke or struggle for breath while sleeping Wake up feeling tired How many hours of sleep Do you have difficulty staying asleep Do you frequently feel fatigued Yes           ___   Patient Name: (Last, First, M) Birth Date: Sex:  M  F How did your symptoms begin? What is your occupation? __________________________________________________________________________________________ Do you have any children living with you? YES  NO  If so, how many children? ____________ Are you: Married  Single  Divorced  Widowed  I have read and understand the above questions. I acknowledge that my questions, if any about the inquiries set forth above, have been answered to my satisfaction. I will not hold Dr. Schuyler VanDyke or Sunset Dental Care responsible for any errors or omissions that I may have made in the completion of this form. I give permission for a letter detailing the findings from my history and examination, including my medical history, to be sent to my healthcare providers and any healthcare providers that I am referred to for care. __________________________________________________ ____________________________ Signature or Authorized Representative’s Signature Date __________________________________________________ Printed Name __________________________________________________ Email Address