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Questionnaire

Orthopedic and TMJ Physical Therapy Center Confidental Health Questionnaire

Jaw & Face Problems

Jaw Related Questions

Does it hurt to chew?
Yes No
Does it hurt to open wide?
Yes No
Do you have headaches?
Yes No
Is it difficult to swallow?
Yes No
Are your teeth sensitive or sore?
Yes No
Dohave implants or splints?
Yes No
Do you have neck pain?
Yes No
Do you have face pain?
Yes No
Is your pain constant?
Aching? Burning? Stabbing? Other?

Worse in the?
Morning Afternoon Evening Night
Do you have problems with your ears?
Hearing Dizziness Other
Does your jaw make a popping noise?
Clicking Grinding Other
Do you ever clench or grind yur teeth?
During the day? At night? Other
Has your jaw ever locked or slipped out of place?
Yes No

General Health Questions

Have you ever had any of the following conditions or Problems? Be descriptive when appropriate.
Anemia Arthritis Asthma Cataracts Cancer Chest Pains Circulatory Problems Constipation / Impaction Convulsions Diabetes Digestive Problems Eliminatory problems Falls Fractures Head Injuries Heart Condition Hemophilia Hemorrhoids High / Low blood pressure HIV, AIDS Irritable Bowel Kidney / Bladder Stones Migraines Mitral valve prolapse Multiple Sclerosis Osteomyelitis Osteoporosis Parkinson's Disease Polyps Phlebitis Pregnancy Trauma Renal Disease Respiratory problems Seizures Skin sensitivities or Condition Thyroid problems Vascular Disease
Musculoskeletal
- TMJ
- Shoulders
- Neck
- Hips
- Back
- Knees
- Feet
Other
When was your last MEdical exam?
Within Last month Within last 6 months More than 6 months
Have you ever been diagnosed for cancer, a tumor, or noticed any lumps or swelling?
Yes No
Do you smoke?
Yes No
Do you drink alcohol? (if so list # per week)
No Beer
Wine
Spirits
Education
High school College Graduate Professional Training
Are you currently under the care of a physician / chiropractor / Therapist / Acupuncturist, counselor, etc.?
Please list all medications you are currently taking (prescription and over the counter)?

Name & Dosage Reason for taking
Indicate what amount you drink of the following in a typical day.
Water (8oz.)
Juice (8oz.)
Coffee (cups)
Tea (cups)
Soda (8oz.)
Please Describe your diet.
Allergies : Medication, food or other
Have you ever been treated for any of the following:
Anxiety Nervous Problems Depression Alcoholism Drug Addiction
Do you experience :
Numbness / tingling / weakness in anywhere in your body Urinary leaking or urge with exercise, laughing, coughing, or on the way to the bathroom Pain with urination or sexual activity
Please list any past injuries, accidents and surgeries (include dates if possible) :
Have you ever seen a physical therapist before?
Yes No
Please list exercise, sports, hobbies or musical instruments
Please describe your sleeping habits (Snoring, # of hours, position, # of pillows)
How did you hear about our clinic?
In your own words please describe your problem :
Life Impairment : What are your feeling about your problem on a scale of 1 to 10?

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Questionnaire

Orthopedic and TMJ Physical Therapy Center Confidental Health Questionnaire

Jaw & Face Problems

Jaw Related Questions

General Health Questions

Name & Dosage	Reason for taking