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Home
About
About
Our Philosophy
Oral Medicine Explained
Team
Team
Oral Medicine Specialists
Dentists
Clinical Staff
Psychologists
Physiotherapists
Administrative Staff
Services
Services
Oral Diseases and Disorders
Oral Ulcers
Altered Sensations of the Mouth
Oral Lumps
Oral Cancer
White and red lesions
Oral Dryness
Orofacial Pain and Temporomandibular Disorders
Temporomandibular Joint (TMJ) Pain
Temporomandibular Joint (TMJ) Noises
Jaw Locking
Clenching and Grinding (Bruxism)
Headaches
Phantom and Persistent Tooth Pain
Trigeminal Neuralgia
Facial Fullness
FAQs
Oral Appliances for Snoring and Sleep Apnoea
Snoring
Obstructive Sleep Apnoea
Mandibular Advancement Appliance
Sleep Apnoea Screening Test
FAQ
Patients
Patients
Your First Visit
Insurance & Payment Options
Instructional Videos
Sleep Videos
Oral Videos
Pain Videos
News
FAQ
Telehealth for Regional Patients
For Referrers
For Referrers
Refer a patient
Perth Oral Medicine Study Club
Tongue & Cheek Newsletter
Upcoming & Past Events
Hot Topics in Oral Medicine
Contemporary Oral Medicine
OralMedMate
Contact
Contact
West Leederville
Jandakot
Padbury
Midland
Home
Home
About
About
Our Philosophy
Oral Medicine Explained
Team
Team
Oral Medicine Specialists
Dentists
Clinical Staff
Psychologists
Physiotherapists
Administrative Staff
Services
Services
Oral Diseases and Disorders
Oral Ulcers
Altered Sensations of the Mouth
Oral Lumps
Oral Cancer
White and red lesions
Oral Dryness
Orofacial Pain and Temporomandibular Disorders
Temporomandibular Joint (TMJ) Pain
Temporomandibular Joint (TMJ) Noises
Jaw Locking
Clenching and Grinding (Bruxism)
Headaches
Phantom and Persistent Tooth Pain
Trigeminal Neuralgia
Facial Fullness
FAQs
Oral Appliances for Snoring and Sleep Apnoea
Snoring
Obstructive Sleep Apnoea
Mandibular Advancement Appliance
Sleep Apnoea Screening Test
FAQ
Patients
Patients
Your First Visit
Insurance & Payment Options
Instructional Videos
Sleep Videos
Oral Videos
Pain Videos
News
FAQ
Telehealth for Regional Patients
For Referrers
For Referrers
Refer a patient
Perth Oral Medicine Study Club
Tongue & Cheek Newsletter
Upcoming & Past Events
Hot Topics in Oral Medicine
Contemporary Oral Medicine
OralMedMate
Contact
Contact
West Leederville
Jandakot
Padbury
Midland
(08) 9376 6789
admin@pomds.com.au
Mon-Fri: 8.30am – 4.30pm
(08) 9376 6789
Phone Number
admin@pomds.com.au
Email Address
Mon-Fri: 8.30am – 4.30pm
Opening Hours
Home
Home
About
About
Our Philosophy
Oral Medicine Explained
Team
Team
Oral Medicine Specialists
Dentists
Clinical Staff
Psychologists
Physiotherapists
Administrative Staff
Services
Services
Oral Diseases and Disorders
Oral Ulcers
Altered Sensations of the Mouth
Oral Lumps
Oral Cancer
White and red lesions
Oral Dryness
Orofacial Pain and Temporomandibular Disorders
Temporomandibular Joint (TMJ) Pain
Temporomandibular Joint (TMJ) Noises
Jaw Locking
Clenching and Grinding (Bruxism)
Headaches
Phantom and Persistent Tooth Pain
Trigeminal Neuralgia
Facial Fullness
FAQs
Oral Appliances for Snoring and Sleep Apnoea
Snoring
Obstructive Sleep Apnoea
Mandibular Advancement Appliance
Sleep Apnoea Screening Test
FAQ
Patients
Patients
Your First Visit
Insurance & Payment Options
Instructional Videos
Sleep Videos
Oral Videos
Pain Videos
News
FAQ
Telehealth for Regional Patients
For Referrers
For Referrers
Refer a patient
Perth Oral Medicine Study Club
Tongue & Cheek Newsletter
Upcoming & Past Events
Hot Topics in Oral Medicine
Contemporary Oral Medicine
OralMedMate
Contact
Contact
West Leederville
Jandakot
Padbury
Midland
Orofacial Pain and Dysfunction form
Home
Orofacial Pain and Dysfunction form
You can
download form as
PDF and send to
forms@pomds.com.au
Title
- Select -
Dr
Mr
Mrs
Ms
Miss
Surname
*
First Name
*
Occupation
Date of Birth
*
Date Format: DD slash MM slash YYYY
Address
*
Street Address
Suburb
ZIP / Postal Code
Telephone (M)
*
Telephone (H)
*
Email Address
*
Work Details
*
(W)
*
Emergency Contact/Next of Kin
*
Relationship
*
(M)
*
(H)
*
Medicare No
Ref
Exp
Date Format: DD slash MM slash YYYY
HCC/Pensioner
Exp
Date Format: DD slash MM slash YYYY
Department of Veteran Affairs
Colour
Exp
Date Format: DD slash MM slash YYYY
Private Health
*
- Select -
Yes
No
Insurer Name
*
Is this for Workers’ Compensation
or Motor Vehicle Accident
(Please See Reception)
General Practitioner
*
Address
*
Street Address
Suburb
ZIP / Postal Code
Dentist
*
Address
*
Street Address
Suburb
ZIP / Postal Code
Referred by
*
General Practitioner
Dentist
Other (Details below)
Name
*
Address
*
Street Address
Suburb
ZIP / Postal Code
For additional health practitioners involved in your care, please complete their details below.
Name of Practitioner
*
Specialty
*
Address
*
Street Address
Suburb
ZIP / Postal Code
I agree to the privacy policy.
Privacy Statement: We value your privacy. All of the information, which you provide to us, will be held and used by us in accordance with our Privacy Policy. A copy of our Privacy Policy is attached to this clipboard. Please take the time to read through our Privacy Policy before answering the Questionnaire and speak to one of our staff members if you have any concerns about how we will use your personal information.
1. Please answer the following questionnaire truthfully and to the best of your ability. If ever your health status or medications change, please inform your practitioner at the next appointment.
2. Practice policy is all accounts are settled on the day, immediately after seeing the practitioner.
3. Please note that Medicare rebates are not available. Rebate for services are only available from Private Health Funds. We do not process Private Health Fund rebates for patients at the rooms.
4. The practitioners are not "preferred providers" of any Private Health Fund and have no control over your rebate received.
5. Patients will be charged for missed and late cancellation appointments unless cancelled 24 hours prior to the consult time. DVA, Workers’ Compensation and Motor Vehicle Accident patients will be charged privately for appointments not kept.
6. Some consultations and procedures may not be claimable under Workers’ Compensation, Third Party or General Insurance. We will assist you in directing your bills to the relevant insurance body/solicitors for settlement. However, you are ultimately responsible
for the account irrespective of any disputes with the insurance companies.
7. Please ensure the above information regarding health practitioners involved in your care is current and complete. Correspondence will be sent to all health practitioners listed unless you advise us otherwise.
8. We would appreciate notification of any change of address.
9. CCTV (video only) operates in these premises for security reasons only and not for patient records.
10. I consent to allow my de-identified clinical information and photographs to be used for educational purposes.
I declare that the particulars and information provided are true and correct, and I understand and agree to the above conditions. Further, I hereby authorise Perth Oral Medicine & Dental Sleep Centre and its practitioners, to obtain and release information about my condition to assist in my treatment and/or rehabilitation.
Patient/Guardian Signature
*
Date
*
Date Format: DD slash MM slash YYYY
(If under 18 years): Guardian Name
Guardian Address
*
Phone
*
Do you have a Trust Account or a Third Party that settles your account? If yes, please see Reception.
Do you smoke? If so, how many per day, and for how many years?
- Select -
Yes
No
Details
Are you a past smoker? If so, how many did you smoke and for how many years? When did you stop smoking?
*
- Select -
Yes
No
Details
Do you drink alcohol on a regular basis? If so, how many per day, and for how many years?
*
- Select -
Yes
No
Details
Do you drink coffee, tea or cola? If yes, how much?
*
- Select -
Yes
No
Details
Do you or have you used recreational drugs? If so, please specify.
*
- Select -
Yes
No
Details
Are you taking any tablets or medicines (prescribed or over-the-counter preparations) at present? If yes, please specify.
Do you have any known allergies (penicillin, drugs, latex, and foods)? If yes, please specify.
Do you have any dental treatment that is ongoing? If yes, please specify.
When was your last appointment with a dentist?
DO YOU HAVE, OR HAVE YOU EVER HAD, ANY OF THE FOLLOWING MEDICAL CONDITIONS? (Please tick)
Neck pain
*
Yes
No
Teeth pain
*
Yes
No
Sleep disorders
*
Yes
No
Headache or migraine
*
Yes
No
Teeth clenching or grinding
*
Yes
No
Obsessive compulsive disorder
*
Yes
No
Arthritis
*
Yes
No
Jaw surgery
*
Yes
No
Depression
*
Yes
No
Sinus problems
*
Yes
No
Fibromyalgia
*
Yes
No
Anxiety
*
Yes
No
Sinus problems
*
Yes
No
Fibromyalgia
*
Yes
No
Anxiety
*
Yes
No
Chronic pain
*
Yes
No
Irritable bowel syndrome
*
Yes
No
Post-traumatic stress disorder
*
Yes
No
Do you have any other medical conditions? If yes, please list all other medical conditions.
*
1. When did your jaw, head or oral pain start?
*
2. List in order of importance all of the problems or symptoms which trouble you. Describe them briefly.
*
3. What do you think is the cause of your pain?
*
4. Rate how much pain you are experiencing now by circling a number on the line below:
*
0 - No pain
1 - No pain
2 - Mild pain
3 - Mild pain
4 - Mild pain
5 - Moderate pain
6 - Moderate pain
7 - Severe pain
8 - Severe pain
9 - Most intense pain
10 - Most intense pain
5. Have you had a jaw, head or neck injury that could have caused your pain/problem?
*
Yes
No
If yes, please list the date of the injury(s) and describe.
If yes, please circle a number to indicate how much your jaw, head or neck injury contributes to the cause of your pain/problem?
*
0 - No contribution
1 -
2
3
4
5 - Some contribution
6
7
8
9
10 - Only cause
6. Have you received any prior treatment or evaluation for this problem? Describe briefly.
*
7. Rate how much your pain has interfered with activities over the last 5 days by circling a number on the line below:
*
0 - No interference
1 -
2
3
4
5
6
7
8
9
10 - Unable to complete any activities
8. Rate the usual intensity of your pain throughout the day by circling a number that best represents your pain:
Morning
*
No pain
Mild pain
Moderate pain
Severe pain
Most intense pain
Noon
*
No pain
Mild pain
Moderate pain
Severe pain
Most intense pain
Afternoon
*
No pain
Mild pain
Moderate pain
Severe pain
Most intense pain
Evening
*
No pain
Mild pain
Moderate pain
Severe pain
Most intense pain
Sleep
*
No pain
Mild pain
Moderate pain
Severe pain
Most intense pain
10. Please tick the appropriate boxes for the following questions.
Jaw Pain:
1. Does it hurt when you open your mouth wide or yawn?
*
Does Not Hurt At All
Hurts A Little
Hurts A Lot
Almost Unbearable
Unbearable Pain Without Relief
2. Does it hurt when you chew or use your jaw?
*
Does Not Hurt At All
Hurts A Little
Hurts A Lot
Almost Unbearable
Unbearable Pain Without Relief
3. Does it hurt when you are not chewing or using your jaw?
*
Does Not Hurt At All
Hurts A Little
Hurts A Lot
Almost Unbearable
Unbearable Pain Without Relief
4. Is your pain worse on waking?
*
Does Not Hurt At All
Hurts A Little
Hurts A Lot
Almost Unbearable
Unbearable Pain Without Relief
5. Do you have pain in front of your ears or an ear ache?
*
Does Not Hurt At All
Hurts A Little
Hurts A Lot
Almost Unbearable
Unbearable Pain Without Relief
6. Do you have jaw muscle (cheek) pain?
*
Does Not Hurt At All
Hurts A Little
Hurts A Lot
Almost Unbearable
Unbearable Pain Without Relief
7. Do you have pain in your temples?
*
Does Not Hurt At All
Hurts A Little
Hurts A Lot
Almost Unbearable
Unbearable Pain Without Relief
8. Do you have pain or soreness in your teeth?
*
Does Not Hurt At All
Hurts A Little
Hurts A Lot
Almost Unbearable
Unbearable Pain Without Relief
Jaw Pain:
1. Does your jaw joint make a noise that bothers you or others?
*
No
Maybe A Little
Quite A Lot
Almost All The Time
All The Time Without Stopping
2. Do you find it difficult to open your mouth wide?
*
No
Maybe A Little
Quite A Lot
Almost All The Time
All The Time Without Stopping
3. Does your jaw ever lock closed so you cannot open it?
*
No
Maybe A Little
Quite A Lot
Almost All The Time
All The Time Without Stopping
4. Does your jaw ever lock open so you cannot close it?
*
No
Maybe A Little
Quite A Lot
Almost All The Time
All The Time Without Stopping
5. Do you have an uncomfortable bite?
*
No
Maybe A Little
Quite A Lot
Almost All The Time
All The Time Without Stopping
Jaw Habits:
1. Do you clench or grind your teeth during the day?
*
No
Maybe A Little
Quite A Lot
Almost All The Time
All The Time Without Stopping
2. Do you clench or grind your teeth during sleep?
*
No
Maybe A Little
Quite A Lot
Almost All The Time
All The Time Without Stopping
3. Do you chew gum frequently?
*
No
Maybe A Little
Quite A Lot
Almost All The Time
All The Time Without Stopping
4. Do you bite your fingernails?
*
No
Maybe A Little
Quite A Lot
Almost All The Time
All The Time Without Stopping
5. Do you rest your chin on your palm?
*
No
Maybe A Little
Quite A Lot
Almost All The Time
All The Time Without Stopping
6. Do you participate in habits/activities involving your jaw? eg musical instruments.
*
No
Maybe A Little
Quite A Lot
Almost All The Time
All The Time Without Stopping
11. Some of the words below describe pain. Circle any words that describe your pain. However, you may only circle one word in each box. You do not have to circle a word in every box.
1
*
- Select -
Flickering
Quivering
Pulsing
Throbbing
Beating
Pounding
2
*
- Select -
Jumping
Flashing
Shooting
3
*
- Select -
Pricking
Boring
Drilling
Stabbing
Lancinating
4
*
- Select -
Sharp
Cutting
Lacerating
5
*
- Select -
Pinching
Pressing
Gnawing
Cramping
Crushing
6
*
- Select -
Tugging
Pulling
Wrenching
7
*
- Select -
Hot
Burning
Scalding
Searing
8
*
- Select -
Tingling
Itchy
Smarting
Stinging
9
*
- Select -
Dull
Sore
Hurting
Aching
Heavy
10
*
- Select -
Tender
Taut
Rasping
Splitting
11
*
- Select -
Tiring
Exhausting
12
*
- Select -
Sickening
Suffocating
13
*
- Select -
Fearful
Frightful
Terrifying
14
*
- Select -
Punishing
Gruelling
Cruel
Vicious
Killing
15
*
- Select -
Wretched
Blinding
12
*
- Select -
Sickening
Suffocating
16
*
- Select -
Annoying
Troublesome
Miserable
Intense
Unbearable
17
*
- Select -
Spreading
Radiating
Penetrating
Piercing
18
*
- Select -
Tight
Numb
Drawing
Squeezing
Tearing
19
*
- Select -
Cool
Cold
Freezing
20
*
- Select -
Nagging
Nauseating
Agonising
Dreadful
Torturing
12. Circle one word that best describes the pattern of your pain.
*
Continuous
Steady
Constant
*
Varying
Rhythmic
Periodic
Intermittent
*
Brief
Momentary
Transient