Musculoskeletal Screening Questionnaire

Musculoskeletal Screening Questionnaire
Date :*

DayMonthYear
Name :*

First NameLast Name
Date of Birth :

DayMonthYear
Referred By :
One or more of the following symptoms may be indicative of Musculoskeletal Dysfunction of the head and neck. If you have any of the following symptoms, please indicate by circling the appropriate areas.
a. Pain in the jaw joints

LeftRight
b. Pain in ear

LeftRight
c. Pain around eyes

LeftRight
d. Pain in lower jaw

LeftRight
e. Pain in upper jaw

LeftRight
e. Pain in neck

LeftRight
e. Pain in shoulder

LeftRight
f. Pain in forehead

LeftRight
i. Pain in temples

LeftRight
j. Pain in facial muscles

LeftRight
k. Grating sound in joint

LeftRight
l. Subjective hearing loss

LeftRight
m. Clicking, snapping, or popping sound in joint

YesNo
- If Present, Is it in

LeftRight
n. Dizziness (vertigo)

YesNo
o. Upset stomach-nausea

YesNo
p. Ringing sound in ears

LeftRight
q. Headache

LeftRight
r. Fullness, pressure,blockage in ear

LeftRight
s. Pain in tongue

YesNo
t. Partial inability to open mouth

YesNo
- If yes, is it

ConstantSporadic
u. Difficulty chewing

YesNo
v. Difficulty swallowing

YesNo
w. Loud snoring

YesNo
x. Constantly tired

YesNo
y. Mouth breath at night

YesNo
z. Awaken with a dry mouth

YesNo
- If yes,

FrequentlyRarelyNever
1. What are your chief complaints? List from most to least important.
Other symptoms (please write in)
Do symptoms affect one or both joints?

RightLeftBoth
If both joints, indicate which joint seems most affected

LeftRight
3. How many years, months, weeks or days have you been bothered by this problem?
4. Have you had any injury to the jaw or face?

YesNo
5. Do you have arthritis?

YesNo
6. Have you had cervical traction?

YesNo
7. Have you ever worn a neck brace?

YesNo
8. Have you had any other treatment for this problem?

YesNo
(If yes, explain – medicine, exercise, dental appliances such as a splint, or night guard.)
9. Have you had your teeth straightened (orthodontia)?

YesNo
10. Have you had teeth removed for orthodontia?

YesNo
11. Have you had your wisdom teeth removed?

YesNo
11. Have you had your wisdom teeth removed?

YesNo
12. Have you ever had general anesthesia?

YesNo
13. Did you have allergies as a child?

YesNo
14. Have you had your bite adjusted by your dentist? (Equilibration)

YesNo
If yes please explain when
15. Do you attribute the symptoms to any one incident?

YesNo
If yes, explain,
16. Have you had cortisone injected into a joint?

YesNo
If yes, when?
How many injections?
By whom?
17. Are you now on any medication?

YesNo
If yes, what kind and how much?
18. Do you know if you clench your teeth?

YesNo
19. Has anyone mentioned that you grind your teeth (brux) at night during sleep?

YesNo
20. Do you chew gum ?

FrequentlyModeratelyInfrequentlyNever
21. Please list chronologically, names and types of doctors and their locations, whom you have seen in the past for this or related problems. Write on back of this sheet if necessary.
22. Please write in any other pertinent information that has not been covered previously.Write on back of sheet if necessary.
23. Are you in litigation or planning litigation?

YesNo
If so explain ,
Patients Name :*

First NameLast Name
Date :*

DayMonthYear
Should be Empty: