Headache and Facial Pain Screening Questionnaire

Please note that it is important to fill in all the fields before submitting. Thank you.

Temporomandibular Disorders are a frequent cause of headaches, facial pain and dental pain. Please complete this screening questionnaire.
Patient Name :
*Last Name:
Middle Name: *First Name:
SYMPTOM CHECKLIST: Please check any of the following symptoms that apply to you. (L=left and R=right)
Headaches: Migraines Tension Headaches Other :
How often?
Top of Head Left Right Forehead Left Right
Back of Head Left Right Pain in Head Left Right
Pain in Ear Left Right Dizziness (vertigo) Left Right
Pain in Jaw Joint Left Right Temples Left Right
Behind Eyes Left Right Pain in Shoulder Left Right
Ear Congestion Left Right Tinnitus (ringing in ears) Left Right
Facial Pain (non-specific) Left Right Grating sound in joint Left Right
Clicking/popping in jaw joint Left Right
Face muscle twitch Yes No Difficulty swallowing Yes No
Difficulty chewing Yes No Difficulty breathing through nose Yes No
Partial inability to open mouth? Yes No Constant : Sporadic :
Have you ever worn braces Yes No Age when braces were on :
Orthodontist :
We have seen a recent increase of sleep apnea findings in our patients, which is a life threatening medical problem. To protect your health, we are asking you to complete the following screening form.
Do you snore? Yes No
Are you excessively tired during the day? Yes No
Have you been told you stop breathing during sleep? Yes No
Do you have a history of hypertension? Yes No
Is your neck size greater than... 17 inches (male)/16 inches (female) Yes No
YES to two or more of these questions is a positive screen for sleep apnea. If you answered yes to two or more questions, show this completed questionnaire to your doctor.

*Signature :
Date :