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HEADACHE AND FACIAL PAIN QUESTIONNAIRE

For New Patients with TMJ/TMD Or Headache and Facial Pain:

If you are going to be a new patient of ours, you may like to save yourself some time by filling out the following form. We have given you the choice of filling out an electronic form and a printable form. Click here for the printable form and when the page fully loads, select the print option from your browser's menu. When the form has been printed, please fill it out to the best of your knowledge and bring it into the office.

Our electronic form can be found below. Simply fill out the empty fields and select the appropriate options for your answers.

Please start by telling us your name and e-mail address:

Name: (required)

E-Mail: (required)

1.) When did your pain start?

Days ago Weeks ago Months ago
Years ago At approximately the age of:

2.) Is the pain...

Slight Moderate Severe

3.) On a scale of 1 - 10 (1 being slight, 10 being the worst pain you've had), how would you rate your pain today?

4.) On a scale of 1 - 10 (1 being slight, 10 being the worst pain you've had), how would you rate your pain on average this past week?

5.) On a scale of 1 - 10 (1 being slight, 10 being the worst pain you've had), how would you rate your pain on average this past month?

6.) Do other members of your family have headaches?

Yes No

7.) Did the pain begin...

Slowly All of a sudden

8.) Do you know what started the pain?

9.) Does the pain feel like it is...

Dull/Aching Pulsing Burning
Sharp stabs Electrical  

10.) When you get the headache, do you want to lie down in a dark room?

Yes No

11.) Does the pain start from the jaw and refer to...

Temples Head Neck

12.) Does the pain start from the neck and refer to...

Back of head Top of head Front of head
Between the eyes or nose The teeth Can't tell

13.) Please place a checkmark beside the feelings/symptoms your experience during your headache...

Visual changes

Nausea

Sensitivity to light

Sensitivity to sound

Sensitivity to smell

Swelling

14.) Does your headache feel like it happens regularly around your period?

Yes No

15.) Does the pain feel like it is squeezing like a band around your head?

Yes No

16.) Does the pain feel like it is intense around the face, skin, inside the month and is triggered by light touch of wind?

Yes No

17.) In the course of a day how many times do you get pain?

1 - 5 per day 1 - 15 per day Other

18.) Does the pain last seconds to minutes?

Yes No

19.) Does the pain last minutes to about an hour?

Yes No

20.) Does the pain wake you from your sleep?

Yes No

21.) Do you feel anxious and want to move around?

Yes No

22.) Does your nose get runny?

Yes No

23.) Do your eyes get teary?

Yes No

24.) Is the pain present...

Daily Weekly Monthly
For a prolonged amount of time

25.) Is the pain always there and never changes except to get worse and affected by the position of your body?

Yes No

26.) Does the pain feel like it went away for...

Weeks Months Years

27.) ...and when the pain went away, did it come back?

Yes No

28.) How many kinds of headaches do you get? Please describe them...

29.) Did the pain use to feel like it used to be occasional and more intense, but now it is less painful and always there?

Yes No

30.) Have you ever stopped taking your medicine and found that the pain became severe until you took the medicine again?

Yes No

31.) Would you like to add anything you would like the doctor to know about the pain? Or anything else?

 

 

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