Orofacial pain

NeuralgiaTrigeminal neuralgia Typical AtypicalPost herpetic neuralgiaPost traumatic neuralgia

NeurovascularMigraineMigrainous neuralgiaGiant cell arteritisCluster headachesTension headacheTrigeminal autonomic SUNCT SUNA

Idiopathic / Persistent Burning mouth syndromeAtypical facial painAtypical odontalgia

Other cause found

Non classifiable

Trigeminal nerve injuryHospital number Patients sticker

Date examinationDate injuryMechanism of injury ID block

Surgery (TMS, Biopsy)Implant Other

Date repair Improvement Y/NNerveRMHComments:Pain Y/N Constant / Intermittent

Evoked / Spontaneous What cause? At rest/ taste /movement/cold

Pain descriptive Dull / Sharp Burning/AcheShooting / stabbing

Altered sensation Y/N Numbness Paraesthesia pins/needlesAllodyniaHyperalgesiaNeuralgia

Function Eating / tongue bitingDrinking Sleeping SpeakingKissingShaving / makeupChange in taste Y / N

no pain worst pain imaginableTESTSCNTs Y/N Questionnaire Y/N

EMG Y/N Electrical Y/NThermal Y/N Capsaicin Y/NEthyl Chloride Y/NPhoto Y/N At restno pain worst pain imaginableCapsaicinno pain worst pain imaginableTouchno pain worst pain imaginableSpicy foodsno pain worst pain imaginableCranial NervesI II III IV V a b c VI VII VIII IX X XIIArea

CNTsArea %

Right Left

Two point discriminationSOIOULLLChinTongue latTongue tipTongue ventThermalSemmes Weinstein / Light touchSOIOULLLChinTongue latTongue tipTongue ventCapsaicinECSharp/bluntLipTongueHypoalgesiaPain thresholdLipTonguePalpation LNPainNeuralgiaPapillae countSubjective functionMoving point discrimination Static DynamicTasteSweetSourBitterSaltAllodynia – static/moving

- cold- taste- capsaicin

TREATMENT HISTORYOn the list below, indicate Yes or No for each treatment listed. For each treatment recommended by a health care professional for your facial pain or jaw problem, indicate how helpful you found it. If recommended, how helpful was treatment?

Recommended If recommended, how helpful was treatment?

No YesVeryHelpf

ul

SomewhatHelpful

NotHelpful

MadeWorse

Did Not Do

a. Mouth appliance (“bite plate,” “night guard,” “repositioning appliance,” “splint”)

0 1 1 2 3 4 5

b. Physical therapy (heat, cold packs, stretching) 0 1 1 2 3 4 5

c. Relaxation training/biofeedback

0 1 1 2 3 4 5

d. Physical exercise (running, bicycling)

0 1 1 2 3 4 5

e. Stress management/counseling

0 1 1 2 3 4 5

f. Change of diet 0 1 1 2 3 4 5

g. Muscle relaxant medications 0 1 1 2 3 4 5

h. Analgesics or “painkillers” 0 1 1 2 3 4 5

i. Anti-inflammatory medications

0 1 1 2 3 4 5

j. Anti-depressant medications 0 1 1 2 3 4 5

k. Anti-anxiety medications 0 1 1 2 3 4 5

l. Other medications - please describe:

0 1 1 2 3 4 5

0 1 1 2 3 4 5

0 1 1 2 3 4 5

m. Bite adjustment 0 1 1 2 3 4 5

n. Orthodontics 0 1 1 2 3 4 5

o. Dental reconstruction (crowns, bridges)

0 1 1 2 3 4 5

p. Muscle or joint injections 0 1 1 2 3 4 5

q. Surgery 0 1 1 2 3 4 5

r. Chiropractic manipulation 0 1 1 2 3 4 5

s. Evaluation and/or referral 0 1 1 2 3 4 5

t. Other treatment - please describe:

Dates Name specialty of clinician

0 1 1 2 3 4 5

0 1 1 2 3 4 5

0 1 1 2 3 4 5

MEDICATION USEDo you require antibiotic medication before dental treatment? List all drugs and medications you are currently taking for any purpose.

Prescription MedicationsNonprescription Medications

(for example, aspirin, laxatives, antacids, diet pills

herbal remedies, marijuana, other “street” drugs)

1. 1.2. 2.3. 3.4. 4.5. 5.6. 6.

SPECIALISTS SEENType location date and treatment receivedType of specialist GMP, Ear Nose Throat, Neurologist, neurosurgeon, maxillofacial, dentist, acupuncture, cranio osteopathy, physio, speech therapist, other

Type and date seen Hospital Treatment received / Diagnosis

HAD Scale

Doctors are aware that emotions play an important part in illnesses and this questionnaire is designed to help your doctor know how you feel. Read each item and place a firm tick in the box opposite the reply, which comes closest to how you have been feeling in the past week.

Don’t take too long over your replies; your immediate reaction to each item will probably be more accurate than a long thought-out response.

Tick one box only in each section

1 I feel tense or wound up:Most of the timeA lot of the timeTime to time, occasionallyNot at all

2 I still enjoy the things I used to enjoy:Definitely as muchNot quite so muchOnly a little Hardly at all

3 I get a sort of frightened feeling as if something awful is about to happen:Very definitely and quite badlyYes, but not too badlyA little, but it doesn’t worry meNot at all

4 I can laugh and see the funny side of things:As much as I always couldNot quite so much nowDefinitely not so much nowNot at all

5 Worrying thoughts go through my mind:A great deal of the time A lot of the timeFrom time to time bur not too oftenOnly occasionally

6 I feel cheerfulNot at allNot oftenSometimesMost of the time

7 I can sit at ease and feel relaxed:DefinitelyUsuallyNot oftenNot at all

8 I feel as if I am slowed down:Nearly all the timeVery oftenSometimesNot at all

9 I get a sort of frightened feeling like “butterflies” in the stomach:Not at allOccasionallyQuite oftenVery often

10 I have lost interest in my appearance:DefinitelyI don’t take so much care as I shouldI may not take quite as much care I take just as much care as ever

11 I feel restless as if I have to be on the move:Very much indeedQuite a lotNot very muchNot at all

12 I look forward with enjoyment to things:As much as I ever didRather less than I used to Definitely less than I used to Hardly at all

13 I get sudden feelings of panic:Very often indeedQuite oftenNot very oftenNot at all

14 I can enjoy a good book or radio or TV programme:OftenSometimesNot oftenVery seldom

McGill QuestionnaireNAME: DATE:Circle the word that describes how your pain feels right now:

Nil MildModerateSevereMost severe

Circle the words below that best describe your current pain.Use only one word in each group.Leave out any group if the words are unsuitable.

1 2 3 4

FlickeringQuiveringPulsingThrobbingBeatingPounding

JumpingFlashing Shooting

PrickingBoring Drilling StabbingLancinating

SharpCutting Lacerating

5 6 7 8

PinchingPressing GnawingCrampingCrushing

TuggingPullingWrenching

HotBurningScaldingSearing

Tingling IthcySmarting Stinging

9 10 11 12

DullSoreHurtingAchingHeavy

TenderTautRaspingSplitting

TiringExhausting

SickeningSuffocating

13 14 15 16

FearfulFrightfulTerrifying

PunishingGruellingCruelViciousKilling

WretchedBlinding

AnnoyingTroublesomeMiserableIntenseUnbearable

17 18 19 20SpreadingRadiatingPenetratingPiercing

TightNumbDrawingSqueezingTearing

CoolColdFreezing

NaggingNauseatingAgonizingDreadfulTorturing

SF36 Health SurveyINSTRUCTIONS: This set of questions asks for your views about your health.

This information will help keep track of how you feel and how well you are able to do your usual activities. Answer very question by marking the answer as indicated. If you are unsure about how to answer a uestion please give the best answer you can.1. In general, would you say your health is: (Please tick one box.)Excellent _Very Good _Good _Fair _Poor _2. Compared to one year ago, how would you rate your health in general now? (Please tick one box.)Much better than one year ago _Somewhat better now than one year ago _About the same as one year ago _Somewhat worse now than one year ago _Much worse now than one year ago _3. The following questions are about activities you might do during a typical day. Does your healthnow limit you in these activities? If so, how much? (Please circle one number on each line.)ActivitiesYes, Limited A Lot Limited A Little Not Limited At All3(a) Vigorous activities, such as running, lifting heavy objects, participating in strenuous sportsYes, Limited A Lot Limited A Little Not Limited At All3(b) Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golfYes, Limited A Lot Limited A Little Not Limited At All3(c) Lifting or carrying groceries Yes, Limited A Lot Limited A Little Not Limited At All3(d) Climbing several flights of stairsYes, Limited A Lot Limited A Little Not Limited At All3(e) Climbing one flight of stairsYes, Limited A Lot Limited A Little Not Limited At All3(f) Bending, kneeling, or stoopingYes, Limited A Lot Limited A Little Not Limited At All3(g) Waling more than a mile Yes, Limited A Lot Limited A Little Not Limited At All3(h) Walking several blocks Yes, Limited A Lot Limited A Little Not Limited At All3(i) Walking one block Yes, Limited A Lot Limited A Little Not Limited At All3(j) Bathing or dressing yourself Yes, Limited A Lot Limited A Little Not Limited At All4. During the past 4 weeks, have you had any of the following problems with your work or otherregular daily activities as a result of your physical health? Yes No4(b) Accomplished less than you would like Yes No4(c) Were limited in the kind of work or other activities Yes No4(d) Had difficulty performing the work or other activities (for example, it tookextra effort) Yes No5. During the past 4 weeks, have you had any of the following problems with your work or otherregular daily activities as a result of any emotional problems (e.g. feeling depressed or anxious)?

Yes No 5(a) Cut down on the amount of time you spent on work or other activities Yes No5(b) Accomplished less than you would like Yes No5(c) Didn’t do work or other activities as carefully as usual

Yes No

6. During the past 4 weeks, to what extent has your physical health or emotional problems interferedwith your normal social activities with family, friends, neighbours, or groups? (Please tick one box.)Not at all _Slightly _Moderately _Quite a bit _Extremely _7. How much physical pain have you had during the past 4 weeks? (Please tick one box.)None _Very mild _Mild _Moderate _Severe _Very Severe _8. During the past 4 weeks, how much did pain interfere with your normal work (including both workoutside the home and housework)? (Please tick one box.)Not at all _A little bit _Moderately _Quite a bit _Extremely _9. These questions are about how you feel and how things have been with you during the past 4weeks. Please give the one answer that is closest to the way you have been feeling for each item.(Please circle one number on each line.)1. All of the Time2. Most of the Time A Good Bit of the Time3. Some of the Time4. A Little of the Time5. None of the Time9(a) Did you feel full of life? 1 2 3 4 5 69(b) Have you been a very nervous person? 1 2 3 4 5 69(c) Have you felt so down in the dumps that nothing could cheer you up? 1 2 3 4 5 69(d) Have you felt calm and peaceful? 1 2 3 4 5 69(e) Did you have a lot of energy? 1 2 3 4 5 69(f) Have you felt downhearted and blue? 1 2 3 4 5 69(g) Did you feel worn out? 1 2 3 4 5 69(h) Have you been a happy person? 1 2 3 4 5 69(i) Did you feel tired? 1 2 3 4 5 610. During the past 4 weeks, how much of the time has your physical health or emotional problemsinterfered with your social activities (like visiting with friends, relatives etc.) (Please tick one box.)All of the time _Most of the time _Some of the time _A little of the time _None of the time _11. How TRUE or FALSE is each of the following statements for you?(Please circle one number on each line.) DefinitelyTrue Mostly True Don’t Know Mostly False DefinitelyFalse11(a) I seem to get sick a little easier than other people 1 234511(b) I am as healthy as anybody I know 1 2 3 4 511(c) I expect my health to get worse 1 2 3 4 511(d) My health is excellent 1 2 3 4 5Thank You

BPI

Temporomandibular Joint pain / Orofacial PainHospital number Patients sticker

Date examinationDate startedPrecipitating episode?Injury

TraumaSurgery (TMS, Bx)Implant Other

Previously treated Y/N Improvement Y/NRight Left Bilateral Other joint pains?RMH Comments:Pain Y/N Constant / Intermittent Frequency

Evoked / Spontaneous What cause? At rest/ taste /movement/cold

Pain descriptive Dull / Sharp Burning/AcheShooting / stabbing

Pain centre Radiation toFunction Eating

Drinking Sleeping Speaking

At restno pain

worst pain imaginable

Eatingno pain

worst pain imaginable

Openingno pain

worst pain imaginable

Pain worse Morning / eveningDiet altered Y/N BruxistGum chewing ClencherTESTSJoint examination

Trismus Y/N Opening max (mm)Opening deviation

Full lateral movement Swelling / asymmetry R-LCentre line coincident Y/N Max R-L Mandible R-L (mm)Pain on palpation joints Y/N Chin midlineClicking R – LPre Mid Post

Crepitus

Locked opening Locked closingOcclusionClass I II III

Ant open bitePost open bite

AttritionQuestionnaire Y/N Cranial NervesI II III IV V a b c VI VII VIII IX X XIIArea

TREATMENT HISTORYOn the list below, indicate Yes or No for each treatment listed. For each treatment recommended by a health care professional for your facial pain or jaw problem, indicate how helpful you found it. If recommended, how helpful was treatment?

Recommended If recommended, how helpful was treatment?

No YesVeryHelpf

ul

SomewhatHelpful

NotHelpful

MadeWorse

Did Not Do

a. Mouth appliance (“bite plate,” “night guard,” “repositioning appliance,” “splint”)

0 1 1 2 3 4 5

b. Physical therapy (heat, cold packs, stretching) 0 1 1 2 3 4 5

c. Relaxation training/biofeedback

0 1 1 2 3 4 5

d. Physical exercise (running, bicycling)

0 1 1 2 3 4 5

e. Stress management/counseling

0 1 1 2 3 4 5

f. Change of diet 0 1 1 2 3 4 5

g. Muscle relaxant medications 0 1 1 2 3 4 5

h. Analgesics or “painkillers” 0 1 1 2 3 4 5

i. Anti-inflammatory medications

0 1 1 2 3 4 5

j. Anti-depressant medications 0 1 1 2 3 4 5

k. Anti-anxiety medications 0 1 1 2 3 4 5

l. Other medications - please describe:

0 1 1 2 3 4 5

0 1 1 2 3 4 5

0 1 1 2 3 4 5

m. Bite adjustment 0 1 1 2 3 4 5

n. Orthodontics 0 1 1 2 3 4 5

o. Dental reconstruction (crowns, bridges)

0 1 1 2 3 4 5

p. Muscle or joint injections 0 1 1 2 3 4 5

q. Surgery 0 1 1 2 3 4 5

r. Chiropractic manipulation 0 1 1 2 3 4 5

s. Evaluation and/or referral 0 1 1 2 3 4 5

t. Other treatment - please describe:

0 1 1 2 3 4 5

0 1 1 2 3 4 5

0 1 1 2 3 4 5

. DURING THE PAST SIX MONTHS, HOW OFTEN HAVE YOU HAD EACH OF THE FOLLOWING JAW SYMPTOMS?

How often… Never Sometimes Often Always

a. Does your jaw CLICK or POP when you open or close your mouth or when chewing? 0 1 2 3

b. Does your jaw make a GRATING or GRINDING noise when it opens and closes or when chewing?

0 1 2 3

c. Do your JAW JOINT NOISES prevent you from doing activities that you would otherwise do? 0 1 2 3

d. Does your jaw ACHE or FEEL STIFF when you wake up in the morning? 0 1 2 3

e. Does your jaw HURT WHEN YOU CHEW or shortly after eating?

0 1 2 3

f. Does ache or pain in your jaw LIMIT YOUR ABILITY TO CHEW to the extent that it is difficult to eat?

0 1 2 3

g. Do you wake up in the morning with HEADACHES?

0 1 2 3

h. Do you have NOISES or RINGING in your ears? 0 1 2 3

i. Do your ears feel CONGESTED? 0 1 2 3

j. Have you been told, or do you notice, that you GRIND your teeth or CLENCH your jaw while sleeping at night?

0 1 2 3

k. Does limited ability to use your jaws PREVENT you from doing ACTIVITIES that you would otherwise do?

0 1 2 3

l. Have you ever had your jaw LOCK or CATCH so that it won’t open all the way? (If Never, go to question “n”)

0 1 2 3

m. Was this locking or catching severe enough to interfere with your ABILITY TO EAT? 0 1 2 3

n. Have you ever had your jaw lock or catch so that YOU CAN’T CLOSE IT ALL THE WAY once it’s open?

0 1 2 3

o. During the day, do you GRIND your teeth or CLENCH your jaw?

0 1 2 3

p. Does your BITE feel UNCOMFORTABLE or unusual?

0 1 2 3

15. Was the CAUSE of your pain or jaw limitation related to any of the following factors? Do any of the following factors make your problem WORSE? For each of the items listed below, circle “C” for CAUSE or “W” for WORSE for each one that applies to your facial pain problem.

Physical FactorsOral Function, Habit and

Behavioral Factors Stress-Related FactorsC W Dental Treatment C W Chewing, smiling, C W Family, work,

school, or Type

yawning, or laughing

other stress

Date

C W Clenching, grinding C W Emotional upsetC W Accident

Type

C W Nail biting or other oral

C W Worry or anxiety

Date

habits

C W Feeling “blue”/depression

C W Other:

C W Other:

C W Other:

Date

16. Are your symptoms better or worse at the following times?

17. What activities does your present jaw problem prevent or limit you from doing?

Better

Worse

No Differenc

e

N/A No Yes

No Yes

Upon awakening

1 2 3 4 0 1 Chewing 0 1 Swallowing

During the day

1 2 3 4 0 1 Drinking 0 1 Cleaning teeth or face

In the evening

1 2 3 4 0 1 Exercising 0 1 Yawning

At work 1 2 3 4 0 1 Eating hard foods

0 1 Sexual activity

At home 1 2 3 4 0 1 Eating soft foods

0 1 Talking0 1 Smiling/

laughing0 1 Having your

usual facial appearance

18. PAIN IMPACT

a. About how many days in the LAST SIX MONTHS have you been kept from your usual activities (work, school, housework) because of facial pain?For example: EVERY DAY = 180 days, EVERY OTHER DAY = 90 days, etc.

Days

b. In the PAST SIX MONTHS, how much has facial pain interfered with your daily activities rated on a scale from 0 to 10 where 0 is “No interference” and 10 is “Unable to carry on any activities”?

0 1 2 3 4 5 6 7 8 9 10No interference

Unable to carry on any activities

c. In the PAST SIX MONTHS, how much has facial pain interfered with your ability to take part in recreational, social and family activities?

0 1 2 3 4 5 6 7 8 9 10No interference

Unable to carry on any activities

d. In the PAST SIX MONTHS, how much has facial pain interfered with your ability to work (including housework)?

0 1 2 3 4 5 6 7 8 9 10No interference

Unable to carry on any activities

e. Based on all the things you do to cope or deal with your facial pain, on an average day, how much control do you feel you have over it?

0 1 2 3 4 5 6No control Some control Complete control

f. Based on all the things you do to cope or deal with your facial pain, on an average day, how much are you able to decrease it?

0 1 2 3 4 5 6Can’t decrease it at all Can decrease it

somewhat Can decrease it completely

19. GENERAL MEDICAL INFORMATION - PRESENT

Circle the symptoms listed below that you are PRESENTLY experiencing or HAVE EXPERIENCED FREQUENTLY during the past SIX MONTHS.

GENERAL MUSCULOSKELETAL BEHAVIORALweight loss joint pain angerweight gain swollen joints worrychange in appetite muscle cramping sleep difficultiesalways hungry arm/hand weakness reduced social activitiesalways thirsty problems at

work/home/schoolfrequent urination GASTROINTESTINALtend to feel hot indigestion SKIN CHANGEStend to feel cold reflux/heartburn skin color changesfatigue nausea/vomiting skin itching/burningfaint easily constipation other skin problemsnight sweats diarrhea nail changesbleed easilybruise easily CARDIOVASCULAR NEUROLOGICAL

shortness of breath with exertion

loss of muscle control/paralysis

NOSE/THROAT racing or irregular heart beat

numbness/tingling

congested/runny nose swollen ankles handwriting changesnose bleeds cold ankles/feet memory changesnasal obstruction chest pain/angina neuropathysore throathoarseness/voice changes

RESPIRATORY EARS

mouth breathing/ snoring coughing spells hearing losssleep apnea cough up phlegm ringing ears

wheezing earachesHEAD & NECK frequent colds dizzinessneck pain use more than 2 pillows

to sleeppressure/stuffiness in ears

neck lump/swellingheadache EYES OTHER PAINfacial pain vision changes back painmigraine eye itching abdominal painshoulder dry eyes arm pain

eye pain leg painother pain

Check here if you have none of the symptoms listed above.

20. GENERAL MEDICAL INFORMATIONWould you say your health in general is excellent, very good, good, fair, or poor?

1 Excellent 2 Very Good 3 Good 4 Fair 5 Poor

21. How good a job do you feel you are doing in taking care of your health overall?

1 Excellent 2 Very Good 3 Good 4 Fair 5 Poor

22. Has there been a change in your general health in the past year? 0 No 1 Yes

23.Your physician:

Phone Number: — —

24. Date of your last physical examination: / /

25. a. Are you currently being treated by a physician? 0 No 1 Yes

b. Are you currently being treated by a psychiatrist, psychologist or mental health worker? 0 No 1 Yes

26. Do you engage in regular exercise? 0 No 1 Yes

27.HISTORY OF ILLNESSProvide an answer for each item listed below. Check the “N” column for those conditions you have NEVER had, the “C” column for conditions you CURRENTLY have, and “P” column for the conditions you have had in the PAST.

N C P N C P N C PCancer Injury to face/neck/jaw Kidney diseaseGenetic (inherited) disease Fractures Bladder diseaseLeukemia Concussion UrethritisLymphoma Arthritis Liver diseaseOrgan transplant

Headache Rheumatic feverRheumatoid arthritis Migraine Scarlet feverLupus Erythematosus Back pain PolioOther systemic arthritic

diseaseAbdominal pain Strep throat

Sjogren’s syndrome MononucleosisOther autoimmune disease

Herpes zoster

Diabetes Fungal infections HepatitisThyroid problems Other skin disease Venereal diseaseHormone disorder Genital/anal warts

Gastric ulcer Genital herpesHigh blood pressure ColitisArteriosclerosis Pacreatitis Psychiatric illnessHeart attack/myocardial

infarctionGastritis Anxiety/panic attacks

Angina/chest pain Crohn’s disease DepressionHeart murmur Celiac Sprue Suicide attempt or thoughtsHeart valve problems Gall bladder problems Physical/sexual/emotional

abuseOther heart disease Splenectomy

Irritable bowel syndrome

Drug abuse

Bleeding disorder Alcohol abuseAnemia Emphysema

Pneumonia Prosthetic valve/jointEpilepsy/seizures Bronchitis Head/neck radiation therapyNeuralgia SinusitisStroke Hayfever HIV infectionOther neurological problems

Asthma AIDS

Glaucoma Tuberculosis Other immune disease

Check here if there are words in this section you do not understand.

29. WOMEN ONLYCircle any of the following that apply to you.

Have you had… Are you…a difficult pregnancy using birth control pillsirregular periods PRESENTLY PREGNANT: ______ months

pregnantmenstrual pains going through menopausea hysterectomy postmenopausalovary(ies) removed using hormone therapynone of the above none of the above

30. MAJOR HOSPITALIZATIONS, SURGERIES, AND BLOOD TRANSFUSIONS

Date Reason

/ /______________________________________________

/ /______________________________________________

/ /______________________________________________

Check here if no hospitalizations, surgeries, or blood transfusions.

31. ALLERGIC OR UNUSUAL REACTIONSCircle any of the following you have had an allergic or other unusual reaction to.

Penicillin Other drugs: Other allergies (food, metals, etc.):SulfaAspirinOpiates/codeine

Local anesthesia

Iodine Latex

Check here if no allergic or unusual reactions.

32. MEDICATION USEDo you require antibiotic medication before dental treatment? List all drugs and medications you are currently taking for any purpose.

Prescription MedicationsNonprescription Medications

(for example, aspirin, laxatives, antacids, diet pills

herbal remedies, marijuana, other “street” drugs)

1. 1.2. 2.3. 3.4. 4.5. 5.6. 6.

Check here if you are taking no prescription or nonprescription medications.

DOCTOR’S USE:

33. CAFFEINE, ALCOHOL AND TOBACCO USE

a.Average number of caffeinated beverages you drink in a DAY.

b.you drink in a WEEK.

Coffee 0 1-2 3+ Beer 0 1-2 3-5 6+Tea 0 1-2 3+ Wine 0 1-2 3-5 6+Cola 0 1-2 3+ Spirits/

other0 1-2 3-5 6+

c. Have you EVER used tobacco products? 0 No 1 Yes

If Yes, circle the type(s) of tobacco products.

Cigarette Pipe/cigar Smokeless

Do you CURRENTLY use tobacco products? 0 No 1 Yes

If Yes, circle the average number of uses per DAY.

1 Less than 10 times/day 2 11-20 times/day 3 More than 20 times/day

How many years have you used a tobacco product?

1 Less than 5 years 2 6-10 years 3 11-20 years 4 More than 20 years

34. FAMILY MEDICAL HISTORYMark in either the “Y” for Yes or “N” for No column to indicate any of the following medical problems that have been present in your parents, brothers/sisters, or other close relatives.

Y N Y N Y Ncancer (type: ____________)

allergic disorders TMJ problems

asthmagenetic (inherited disease)

tuberculosis rheumatoid arthritis

arthritis lupus erythematosusstomach/intestinal problems

back pain other systemic arthritic disease

kidney or bladder problems

headache or migraine other immune system disease

liver disease seizuresneurological disease drug abuse

diabetes alcoholismhigh blood pressure

anemia heart disease psychiatric illnessbleeding disorders stroke anxiety/panic attacks

depressionsuicide or attempted suicide

Check here if no one in your family has ever had any of the problems listed above.

DOCTOR’S USE:

35. PREVIOUS DENTAL CAREa. Circle those items that describe your past dental care.

Circle one: Circle all that apply:Regular dental care Wisdom tooth extractions Bite

adjustmentEmergency treatment only

Treatment for jaw trauma/fracture Night guard/splint

Occasional dental care

Periodontal (gum) surgery TMJ problems

Root canal therapy Facial painOrthodontics Other:Gum disease (pyorrhea, gingivitis, or periodontal disease)

b. Would you say your ORAL HEALTH in general is:

1 Excellent

2 Very Good

3 Good 4 Fair 5 Poor

c. How good a job do you feel you are doing in taking care of your oral health?

1 Excellent

2 Very Good

3 Good 4 Fair 5 Poor

Date of your last regular dental visit: / /

Name and address of your dentist:

DOCTOR’S USE:

36. SYMPTOM CHECKLISTIn the LAST MONTH, how much you have been distressed by:

Not at all

A little bit Moderately

Quite a bit

Extremely

a. Headaches 1 2 3 4 5

b. Nervousness or shakiness inside 1 2 3 4 5

c. Faintness or dizziness 1 2 3 4 5

d. Loss of sexual interest or pleasure

1 2 3 4 5

e. Feeling easily annoyed or irritated

1 2 3 4 5

f. Pains in the heart or chest 1 2 3 4 5

g. Feeling low in energy, slowed down

1 2 3 4 5

h. Sleep that is restless or disturbed

1 2 3 4 5

i. Trembling 1 2 3 4 5

j. Poor appetite 1 2 3 4 5

k. Crying easily 1 2 3 4 5

l. Feeling of being caught or trapped

1 2 3 4 5

m. Suddenly being scared for no reason

1 2 3 4 5

n. Blaming yourself for things 1 2 3 4 5

o. Pains in the lower back 1 2 3 4 5

p. Feeling lonely 1 2 3 4 5

q. Feeling blue 1 2 3 4 5

r. Worrying too much about things 1 2 3 4 5

s. Feeling no interest in things 1 2 3 4 5

t. Feeling fearful 1 2 3 4 5

u. Heart pounding or racing 1 2 3 4 5

v. Nausea or upset stomach 1 2 3 4 5

w. Soreness of your muscles 1 2 3 4 5

x. Trouble falling to sleep 1 2 3 4 5

y. Difficulty making decisions 1 2 3 4 5

z. Trouble getting your breath 1 2 3 4 5

aa. Hot or cold spells 1 2 3 4 5

bb. Numbness or tingling anywhere 1 2 3 4 5

cc. A lump in your throat 1 2 3 4 5

dd. Feeling hopeless about the future

1 2 3 4 5

ee. Feeling weak in parts of your body

1 2 3 4 5

ff. Feeling tense or keyed up 1 2 3 4 5

gg. Heavy feelings in your arms or legs

1 2 3 4 5

hh. Thoughts of death or dying 1 2 3 4 5

ii. Overeating 1 2 3 4 5

jj. Awakening in the early morning 1 2 3 4 5

kk. Thoughts of ending your life 1 2 3 4 5

ll. Feeling everything is an effort 1 2 3 4 5

mm. Spells of terror or panic 1 2 3 4 5

nn. Feeling so restless you couldn’t sit still

1 2 3 4 5

oo. Feelings of worthlessness 1 2 3 4 5

pp. The feeling that something bad is going to happen to you 1 2 3 4 5

qq. Thoughts and images of a frightening nature

1 2 3 4 5

rr. Feelings of guilt 1 2 3 4 5

ss. The idea that something serious is wrong with your body 1 2 3 4 5

tt. The idea that something is wrong with your mind 1 2 3 4 5

37. STRESSa. How much stress have you experienced in the PAST MONTH as a result of:

None A little Some A great deal

Home or family concerns 0 1 2 3

Work or school concerns 0 1 2 3

Financial concerns 0 1 2 3

Social or personal relationship 0 1 2 3

Health concerns 0 1 2 3

In general, how much stress have you experienced in the past month?

0 1 2 3

b. Have any of the following events happened to you in the LAST YEAR?No Yes

Change in residence 0 1

Change in marital status (marriage, divorce or separation)

0 1

Change in living arrangement 0 1

Gain or loss of employment 0 1

Retirement of self or spouse 0 1

Birth in the family 0 1

Death of a close friend or relative 0 1

Serious illness or injury of a close family member 0 1

Serious illness of injury of self 0 1

Major change in financial circumstances 0 1

HAD Scale

Doctors are aware that emotions play an important part in illnesses and this questionnaire is designed to help your doctor know how you feel. Read each item and place a firm tick in the box opposite the reply, which comes closest to how you have been feeling in the past week.

Don’t take too long over your replies; your immediate reaction to each item will probably be more accurate than a long thought-out response.

Tick one box only in each section

1 I feel tense or wound up:Most of the timeA lot of the timeTime to time, occasionallyNot at all

2 I still enjoy the things I used to enjoy:Definitely as muchNot quite so muchOnly a little Hardly at all

3 I get a sort of frightened feeling as if something awful is about to happen:Very definitely and quite badlyYes, but not too badlyA little, but it doesn’t worry meNot at all

4 I can laugh and see the funny side of things:As much as I always couldNot quite so much nowDefinitely not so much nowNot at all

5 Worrying thoughts go through my mind:A great deal of the time A lot of the timeFrom time to time bur not too oftenOnly occasionally

6 I feel cheerfulNot at allNot oftenSometimesMost of the time

7 I can sit at ease and feel relaxed:DefinitelyUsuallyNot oftenNot at all

8 I feel as if I am slowed down:Nearly all the timeVery oftenSometimesNot at all

9 I get a sort of frightened feeling like “butterflies” in the stomach:Not at allOccasionallyQuite oftenVery often

10 I have lost interest in my appearance:DefinitelyI don’t take so much care as I shouldI may not take quite as much care I take just as much care as ever

11 I feel restless as if I have to be on the move:Very much indeedQuite a lotNot very muchNot at all

12 I look forward with enjoyment to things:As much as I ever didRather less than I used to Definitely less than I used to Hardly at all

13 I get sudden feelings of panic:Very often indeedQuite oftenNot very oftenNot at all

14 I can enjoy a good book or radio or TV programme:OftenSometimesNot oftenVery seldom

NAME: DATE:

Circle the word that describes how your pain feels right now:

Nil MildModerateSevereMost severe

Circle the words below that best describe your current pain.Use only one word in each group.Leave out any group if the words are unsuitable.

1 2 3 4

FlickeringQuiveringPulsingThrobbingBeatingPounding

JumpingFlashing Shooting

PrickingBoring Drilling StabbingLancinating

SharpCutting Lacerating

5 6 7 8

PinchingPressing GnawingCrampingCrushing

TuggingPullingWrenching

HotBurningScaldingSearing

Tingling IthcySmarting Stinging

9 10 11 12

DullSoreHurtingAchingHeavy

TenderTautRaspingSplitting

TiringExhausting

SickeningSuffocating

13 14 15 16

FearfulFrightfulTerrifying

PunishingGruellingCruelViciousKilling

WretchedBlinding

AnnoyingTroublesomeMiserableIntenseUnbearable

17 18 19 20

SpreadingRadiatingPenetratingPiercing

TightNumbDrawingSqueezingTearing

CoolColdFreezing

NaggingNauseatingAgonizingDreadfulTorturing

SF36 Health Survey

INSTRUCTIONS: This set of questions asks for your views about your health. This information will help keep track of how you feel and how well you are able to do your usual activities. Answer very question by marking the answer as indicated. If you are unsure about how to answer a uestion please give the best answer you can.1. In general, would you say your health is: (Please tick one box.)Excellent _Very Good _Good _Fair _Poor _2. Compared to one year ago, how would you rate your health in general now? (Please tick one box.)Much better than one year ago _Somewhat better now than one year ago _About the same as one year ago _Somewhat worse now than one year ago _Much worse now than one year ago _3. The following questions are about activities you might do during a typical day. Does your healthnow limit you in these activities? If so, how much? (Please circle one number on each line.)ActivitiesYes, Limited A Lot Limited A Little Not Limited At All3(a) Vigorous activities, such as running, lifting heavy objects, participating in strenuous sportsYes, Limited A Lot Limited A Little Not Limited At All3(b) Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golfYes, Limited A Lot Limited A Little Not Limited At All3(c) Lifting or carrying groceries Yes, Limited A Lot Limited A Little Not Limited At All3(d) Climbing several flights of stairsYes, Limited A Lot Limited A Little Not Limited At All3(e) Climbing one flight of stairsYes, Limited A Lot Limited A Little Not Limited At All3(f) Bending, kneeling, or stoopingYes, Limited A Lot Limited A Little Not Limited At All3(g) Waling more than a mile Yes, Limited A Lot Limited A Little Not Limited At All3(h) Walking several blocks Yes, Limited A Lot Limited A Little Not Limited At All3(i) Walking one block Yes, Limited A Lot Limited A Little Not Limited At All3(j) Bathing or dressing yourself Yes, Limited A Lot Limited A Little Not Limited At All4. During the past 4 weeks, have you had any of the following problems with your work or otherregular daily activities as a result of your physical health? Yes No4(b) Accomplished less than you would like Yes No4(c) Were limited in the kind of work or other activities Yes No4(d) Had difficulty performing the work or other activities (for example, it tookextra effort) Yes No5. During the past 4 weeks, have you had any of the following problems with your work or otherregular daily activities as a result of any emotional problems (e.g. feeling depressed or anxious)?

Yes No 5(a) Cut down on the amount of time you spent on work or other activities Yes No5(b) Accomplished less than you would like Yes No5(c) Didn’t do work or other activities as carefully as usual

Yes No

6. During the past 4 weeks, to what extent has your physical health or emotional problems interferedwith your normal social activities with family, friends, neighbours, or groups? (Please tick one box.)Not at all _Slightly _Moderately _Quite a bit _Extremely _7. How much physical pain have you had during the past 4 weeks? (Please tick one box.)None _Very mild _Mild _Moderate _Severe _Very Severe _8. During the past 4 weeks, how much did pain interfere with your normal work (including both workoutside the home and housework)? (Please tick one box.)Not at all _A little bit _Moderately _Quite a bit _Extremely _9. These questions are about how you feel and how things have been with you during the past 4weeks. Please give the one answer that is closest to the way you have been feeling for each item.(Please circle one number on each line.)1. All of the Time2. Most of the Time A Good Bit of the Time3. Some of the Time4. A Little of the Time5. None of the Time9(a) Did you feel full of life? 1 2 3 4 5 69(b) Have you been a very nervous person? 1 2 3 4 5 69(c) Have you felt so down in the dumps that nothing could cheer you up? 1 2 3 4 5 69(d) Have you felt calm and peaceful? 1 2 3 4 5 69(e) Did you have a lot of energy? 1 2 3 4 5 69(f) Have you felt downhearted and blue? 1 2 3 4 5 69(g) Did you feel worn out? 1 2 3 4 5 69(h) Have you been a happy person? 1 2 3 4 5 69(i) Did you feel tired? 1 2 3 4 5 610. During the past 4 weeks, how much of the time has your physical health or emotional problemsinterfered with your social activities (like visiting with friends, relatives etc.) (Please tick one box.)All of the time _Most of the time _Some of the time _A little of the time _None of the time _11. How TRUE or FALSE is each of the following statements for you?(Please circle one number on each line.) DefinitelyTrue Mostly True Don’t Know Mostly False DefinitelyFalse11(a) I seem to get sick a little easier than other people 1 234511(b) I am as healthy as anybody I know 1 2 3 4 511(c) I expect my health to get worse 1 2 3 4 511(d) My health is excellent 1 2 3 4 5Thank You!

On the next 3 pages we would like you to tell us how often you have had problems with your mouth, teeth or gums in the last 3 months.

Never Hardly ever Occasionally Fairly often Very often1. Have you had trouble pronouncing any words because of problems with your teeth, mouth or dentures?

2. Have you felt that your sense of taste worsened because of problems with your teeth, mouth or dentures?

3. Have you had painful aching in your mouth?

4. Have you found it uncomfortable to eat any foods because of problems with your teeth, mouth or dentures?

5. Have you been self conscious because of problems with your teeth, mouth or dentures?

6. Have you felt tense because of problems with your teeth, mouth or dentures?

7. Has your diet been unsatisfactory because of problems with your teeth, mouth or dentures?

8. Have you had to interrupt meals because of problems with your teeth, mouth or dentures?

9. Have you found it difficult to relax because of problems with your teeth, mouth or dentures?

10. Have you been a bit embarrassed because of problems with your teeth, mouth or dentures?

11. Have you been irritable with other people because of problems with your teeth, mouth or dentures?

12. Have you had difficulty doing your usual jobs because of problems with your teeth, mouth or dentures?

13. Have you felt that life in general was less satisfying because of problems with your teeth, mouth or dentures?

14. Have you been totally unable to function because of problems with your teeth, mouth or dentures?

1. Do you have altered sensation on the affected side of your lip?

2. What type of sensation do you get on the affected side of your lip?numbness

tingling

more sensitive

discomfort

pain

other describe

3. What causes these pain sensations in your lip?eating touching the affected area

speaking

temperature change brushing teeth

just spontaneous

other comment

4. How bad is the pain?This is a way of recording your pain. A mark at the no pain end of the line means you are completely free of pain. Marks along the line means gradually worse pain, until you get to the other end where your pain is unbearable. Please could you put a mark through the line at the place appropriate for your pain now.

No pain Unbearable pain

Never Hardly ever Occasionally Fairly often Very often4. What causes these tingling sensations in your lip?

eating touching the affected area

speaking

temperature change brushing teeth

just spontaneous

other comment

5. What causes these sensations of discomfort in your lip?eating

touching the affected area

speaking

temperature change brushing teeth

just spontaneous

other comment

6. Do you bite or burn the affected side of your lip?

7. If you are a man, is your shaving affected by the changed sensation of your lip?

8. Do you have problems with dribbling due to the changed sensation of your lip?

9. Is your speech affected by the changed sensation of your lip?

10. Is your kissing affected by the changed sensation in your lip?

11. Any other comment?

Tick only positive ones

Provoking Factor RelievingTalkingEatingBrushing teethShaving/washingBrushing hair/touching templesCold/windWarmthFoods cold or hotPressure on teeth/bitingOpening wideStooping/bendingStress/tension/relaxingSleep/restLying downFatigueDistractionWorkingAlcoholOther please specify

Associated factors: tick if presentPresence Factor Presence Factor

Altered/poor taste Clicking jointDisturbed salivation BruxismAltered sensation/numbness Cheek clenchingSleep disturbance Unable to open wideWaking due to pain Ringing in the earsColour change tissues/redness DeafnessSwelling of face HeadachesNasal stuffiness/post nasal drip

Dizziness

Double or blurred vision Migraine with or without aura

Excessive tearing of eyes Neck painExcessive dryness of eyes Back painVisual disturbances Irritable bowelEye redness NauseaFatigue/loss strength Abdominal pain/menstrualStiffness of joints Impaired concentrationReduced appetite Other please specify

PAST TREATMENTS:Drugs Daily Dosage/ time

usedSide effects Efficacy

Previous surgeryOther treatments: splints dental-cons endodontics, extraction,Alternative medicine, acupuncture/low intensity laser/TENS/homeopathy

Previous consultations/number: GP dentist oral surgeon neurologistpsychiatrist

ENT surgeon neurosurgeon psychologist pain specialist counsellorother

EFFECT OF PAIN AND COPING:

Effect of pain on quality of life: none mild moderate considerableWhat changes have occurred in your life as a result of the pain:

Have you taken time off work: No/Yes how much:

How do people respond to your pain/is it helpful:

Do you feel anxious: no yesIn the last month have you felt a lack of pleasure in life: no yesIn the last month have you felt depressed: no yesDo you have: feeling of worthlessness/guilt/disturbed sleep/early am wakening/ appetite changes

What do you think has caused the pain and what do you think I can do:

Timing/Pattern of pain

Refractory period of no pain observed after a paroxysm of pain for few minutes

Refractory period of no pain observed after a mixture of sharp shooting and dull

(burning) pain

Continuous (persistent) dull aching pain in between each sharp attack

Continuous low-grade dull aching or burning pain

Sharp, shooting

dull, burning burning refractory

pain freeperiod

Dull painaching aching

background

sharp

shooting pain

pain free period

paroxysmal pain

Sharp ,shooting