Orofacial Pain and Dysfunction form - Perth Oral Medicine & Dental Sleep Centre

Title

Surname*

First Name*

Occupation

Date of Birth*

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

HCC/Pensioner

Exp

Department of Veteran Affairs

Colour

Exp

Private Health*

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*

(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?

Details

Are you a past smoker? If so, how many did you smoke and for how many years? When did you stop smoking?*

Details

Do you drink alcohol on a regular basis? If so, how many per day, and for how many years?*

Details

Do you drink coffee, tea or cola? If yes, how much?*

Details

Do you or have you used recreational drugs? If so, please specify.*

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:*

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?*

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:*

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*

2*

3*

4*

5*

6*

7*

8*

9*

10*

11*

12*

13*

14*

15*

12*

16*

17*

18*

19*

20*

12. Circle one word that best describes the pattern of your pain.

*

Continuous
Steady
Constant

*

Varying
Rhythmic
Periodic
Intermittent

*

Brief
Momentary
Transient