QUESTIONNAIRE I. MEDICAL/ DENTAL HISTORY A. General Health: Good Fair Poor
Good Fair Poor
Gastrointestinal (GI) problems (ulcers)
B. Do you have a personal physician?. C. Are you currently under the care of a physician?. D. Have you ever been seriously ill?. E. Have you been hospitalized in the past 5 years?. F. Have you ever had a major operation?.
Sleep disturbance (snoring, night gasping)
G. Women: Are you pregnant?. H. Has there been any change in your general health in the last year?. L. Medications currently taken by the patient? I. Has there been a major weight loss, without dieting, in recent months?. J. Worried about receiving medical/
Bisphosphonates (Fosamax, Didronel, Boniva, Aredia,
dental treatment?. K. Have you now, or in the past, experienced any of the following medical conditions:.
Tranquilizers or Antidepressants (valium, etc.)
M. Allergies to medical and/or food: II. CRANIOFACIAL SYMPTOMS OF THE HEAD, NECK
Fill in the appropriate response square indicating whether or not
you currently have, or previously had, the following conditions or
symptoms, and identify which side, right side R of L where
appropriate: of both sides are involved, mark right and left sides.
5. Do you feel that there is not enough room
43. Have you ever been treated for pain?
6. Missing back teeth with no replacement?
44. Have you ever had injections or nerve
45. Did any of the injections bring relief
48. How often do you take medicine for the relief of pain?
15. Teeth extracted within the past three years? R B. BREATHING PROBLEMS A. CRANIOFACIAL PAIN
20. Do you have generalized facial pain?
22. Does the pain or discomfort disturb you sleep?
23. Would you describe the pain as a dull,
24. Would you describe the pain as stabbing,
25. Do you suffer from chronic headache?
26. Do you ever have migraine headaches?
C. EYE PROBLEMS
30. Are there times when you notice that the pain
or problems are less or gone completely?
31. Do you have pain in teeth on awakening?
32. Do you r teeth hurt from clenching or chewing?
34. Does your jaw hurt when you open wide
D. EAR PROBLEMS
37. Do you have pain in front of the ears?
38. Is the degree of pain same in morning
94. Has your jaw ever locked or were you unable
95. Have you had pain in your jaw joint?
E. EQUILIBRIUM PROBLEMS
96. Do you hear sounds in your jaw joint?
97. Do you hear grating sounds in your jaw joint?
69. Often feel like vomiting or nauseated?
98. Do you hear or feel a clicking or popping in
F. POSTURE PROBLEMS
99. Does your jaw make clicking or popping
100. Does your jaw feel tired after a big meal?
73. Do you have problems sitting still for
102. Do you have pain in your neck and/or
I. TRAUMA RELATED PROBLEMS
106. Have you ever received a severe blow to
G. LIFESTYLE PROBLEMS
109. Have you worn a cervical traction neck
78. Do you bite your nails, tongue, or lips?
110. Has there been a strain or stretching of the
jaw while yawning, chewing, or opening the mouth
111. Have you experienced a fall within the last
J. Are there any other significant medical or dental problems? H. JAW (TMJ) SYMPTOMS III. PRACTITIONERS
84. Have you ever been treated for jaw joint
Please indicate which practitioners you have seen since your pain
88. Are you aware of clenching your teeth
89. Are you aware of clenching your teeth
90. Are there times when you can’t open
91. Do you have difficulty in opening your
COMMENTS: IV. PAIN SUMMARY
Please identify your areas of pain indicating right R and/or left L
that you presently or frequently experience.
To the best of my knowledge, all the preceding answers are
true and correct. If deemed advisable, I grant permission for
my physician to be contacted for information and advice. If I
have any change in my health or medications that is not
reported above, I will inform the doctor at my next visit.
SUPREP ® PREP North Jersey Gastroenterology and Endoscopy Associates 1825 Route 23 South, Wayne, NJ 07470 Telephone 973-633-1484 Patient:_______________________________________________ Doctor: _____________________ Date of procedure:________________ Time to report: _________ Time of procedure:________________ Location: Endoscopy Center, 1st Floor Wayne Surgical Center Chil