Headache, Neckache and Facial Pain Diagnosis

Transcription

Document provided by Dr. Brendan Stack, DDS, MS www.tmjstack.com
Headache, Neckache and Facial Pain Diagnosis
Name
Today's Date
Address
birth_Married _ Separated
_Female
Date of
Home telephone
Occupalion
(area code)
Business telephone
Referred ro this orti""'"d"vi"*
_Divorced _Widowed _Single
-Male
Family Physician
Family Dentist
INSTRUCTIONS: Please answer all the questions as accurately, as honestly, and in as much detail as possible.
The accuracy and completeness of your answers directly affect the diagnostic decisions made on your behatf.
Although some questions may seem "strange" or not applicable to you, there is a specific reason behind each
question asked. Your conf identiality will be respected. Please give this your "best effort".
1. Medicines: Mark an X in the box next to any medicines that you are now taking, or that you are sensitive or
allergic to:
Now
Taking
fl
tJ
Sensitive or
Allergic
Specific Name of Prescription or
Brand Name
to:
I
I
Antibiotics
fl
D
fl
I
D
fl
Il
D
I
D
Penicillin
Sedatives
Barbituates
n
t-l
tr
f]
rr
D
n
n
D
tl
n
Sulf a
-----
Sleeping Pills
Muscle relaxants (Valium, etc.)
Thyroid
lnsulin
!
r______Yr_"_v_Y
Blood IPressure
J soJur s rPills
|| D
|
n
n
!
tr
n
Pain Pills (Demerol, Codiene, etc.)
Cortizone
tJ
rrrD
urgr
Diet FPilts
rJ
Diuretics (water piils)
Heart Pilts (Digitalis, etc.)
Nerve Pills
PLEASE S'G'Y EACH PAGE
-----
signature:
Date:
CONTINUE TO NEXT PAGE
Copyright rg 1976 National Capital Center for Craniofacial Pain. Atl rights reserved.
Page 2
1. Medicines (continued)
Sensitive or
Now Alleroic
Taking To: ASpirin or Aspirin
D
tr
Antacids
tr
D
Laxatives
!
D
tr
tr
---
tr
n
Substitutes
cold Tablets
Allergy Medication
lyl-lt_qqi ggl,-o-n _ - _
Birth Contol Pills
Any other medications
a
- - - - - Q- - - - - -sl
tr
il
U
n
2. Food Allergies: Mark an X in the appropriate box indicating if you have an allergic response to any of the
following foods:
_
Yes
D
tr
No
U
tr
Chinese Food
ltalian Food
Soy Sauce
D
tr
n
tr
D
tr
Milk (or other diary Products)
Cheese (particularly cheese with molds on them)
Brewed Coffee
tr
tr
tr
D
De-caffeinated Coffee
Sugar
D
tr
- --n- - - - - -E- - -Qesr - -
D
D
__
_a_
D
D
____
tr
n
n
D
__
_D_
D
n
tr
_E_
____
-
Wine(s)
Alcohol
_
_E9g-ly-e-al9- - - - - - - - -
Seafood
Fast Foods (McDonald's etc.)
_E_ _ _r_qge : g g-Qev
n
D
n
sc- - - -
Hot Dogs
Cold Cuts
Other:
Signature:
Date:
Copyright Gi 1976 National Capital Center for Craniofacial Pain- All rights reserved.
Page 3
3. Tests and lmmunizations: Mark an X next to those that you have had. Enter the year of the most recent test(s)
and immunization{s).
IMMUNIZATIONS (Please Specify)
TESTS
n 19- brain scan
n 19- electrocardiogram
D 19-TB test
n 19- other x-rays
n 19_
tr
D 19_
tr 19n 19tr 19tr
19_
19_
n 19_
tr19
tr
19_
4. Medical History: Mark an X in the appropriate box indicating whether you have had, or now have, any of the
following conditions or symptoms:
Have
Never Have
Had Had
D
tr
f,
D
tr
I
tr
f
D
!
Now
Have
tr
tr
tr
D
tr
Swotlen, stiff or painfut joints
Osteoarthritis (neck, joints, etc.)
X
D
n
tr
Hearttrouble
Heartmurmer
tr
tr
n
tl
Fast pulse, heart palpations, thumping or racing heart
Low Blood Pressure (hypotension)
[l
tr
n
D
Poorcirculation
tl
D
D
D
Leg cramps at night or when walking
Swollen ankles or feet
Arteriosclerosis
Stroke
Rheumatoidarthritis
_____!____
tr
!
_____F____
tr
tr
_____!____
n
tr
Frequent nose bleeds for no reason at all
_____!____
U
n
D
n
u
tr
____!____lgl_{s_g9l_qqlg.
D
lmplantedPacemaker
Signature:
Date:
Copyright @ 1976 National Capital Center for Craniofacial Pain. All rights reserved.
Page 4
tl. Medlcal Hlstory (continued)
Have
Never Have
Had Had
tr
!
n
tr
Now
Have
tr
tr
Tendency to be too hot or cold
E
tr
Bleed easily from cuts
Slow healing sores
Feet get cold
_____F____
tr
D
n
tr
_____?______tr________n____!t_q1c-lg_s_o_Lelle_lq_o1_s_tjtll'g_s!_
D
!
n
n
tr
il
tr
tr
tr
Muscletremors
Handtremors
Diabetes
I
tr
tr
tr
n
n
tr
tr
More thirsty than usual lately
High or low blood sugar
x
tr
[
n
tr
D
n
I g ger i l-u-rl !9- - - - - - -
D
tr
tr
C
n
n
tl
U
tr
tr
Use extra pillows to help breathing at night
Chronic coughing up phlegm (thick spit)
n
tr
n
tr
Feel exhausted or fatigued most of the time
Difficulty falling asleep or staying asleep
tr
tr
n
tr
tl
tr
tr
!
n
Frequentlyirritable
Ulcers, heartburn or digestive problems
Skin problems, rashes, psoriasis, etc.
n
tr
tl
I
n
E
tr
tr
tr
E
tr
tr
tr
Blood in urine
Asthma
_____F____
D
tr
D
il
I
Frequentcolds
Psychological or psychiatric care
Nervousbreakdown
_____!____
D
D
_____!____
n
tr
!
tr
tr
Fits, convulsions or epilepsy
Schizophrenia
Cerebral Palsy
Parkinson's disease
Multiple sclerosis
ler_{ryrilir_g_glgns_qqr999!!ry__
Signature:
Date:
Copyright@ 1976 National Gapital Genter for Graniofacial Pain. All rights reserved.
Page 5
4. Medlcal Hlstory (continued)
Have
Never Have
Had Had
tr
tr
n
[
Now
Have
..--
Liver disorders, hepatitis, etc.
Heavy metal problems
_____!______tr_________r____U_ono_tgg!_e_qs_r!___
il
tr
___
__tr_
tr
tr
_____
D
I
e
tr
f,
_ _ _ _ _ _ _-r_ _ _
r
X
r
f,
f
!
Endocrine or hormone problems
Birth control pills
_lle_s_!3!gy
Venereat
o;;;---
Cancer
_____F____
tr
Atcohot addiction
5- Head, Neck and Face Symptoms: Mark X in the appropriate box indicating whether you have had, or now
have, any of the following conditions or symptoms, anO' whether it occurred-on the tefi or righi
side or both:
Have
Never Have
Had Had
tr
f
D
I
Now
Left
!U
Have
I
!
Accident or trauma to head, face or neck
Headaches at crown of head
trtr
Dtr
___q______!________!____lleegeg!rg_s_i1_[o_1e.[e_{jeggye_erq?Lo_ry!)_
D
tl
I
I
D
D
Headaches in left or right temple
Headaches in back of head
___q______?________tr____t_tgltinelg._qg9g1_d.,_o_r_!g!ig_ey_e_s-
tr
tr
tr
tr
n
Pain in, around, or behind eyes
D
n
tr Eyelidtics
tr
tr
tr
tr
LJ
n
n
tr Eyesightbturs
n Eyesight getting worse
tr
tr
__E_______E_
n
tr
---A------!________q___4Jle_rsjee_________
tr
tr
tr
tr
LI
___q______F________tr_____ey_e_s_!!i3!9l_qqlel_T_o_s_t_91!!9_ti$_e__
tr
tr
Right
D
n
_________E_______!__
tr Sinusproblems
tr Nose stuffed when you don't have a cold
D
n
D
Snore
D
D
Dizziness or lightheadedness
Motion sickir.ess (c?r-:_11p[l9,_ggg!.glc_.)
tr
fI
n
tr
___F_______F_
tr
tr
U
tr
D
tr
___q______F_
t-t
Signature:
Date:
CONTINUE TO NEXT PAOE
Copyright O 1976 National Capital Genter for Cranlofaclal Pain. Alt rlghts reserved.
Page 6
5. Head, Neck and Face Symptoms (continued)
Have
Never Have
Had Had
D
tr
n
n
Now
tr
tr
vomiting)
ears
E
n
D
tr
tJ
t]
Easity nauseated (feel like
ltchiness or stuffiness in
___a______F________q___E_u'.rrs_99r9______
tr
tr
Left
Have
Excessive ear wax formed
Ringing, hissing or buzzing sounds in
Right
tr
t]
________A_______A___
ears
il
D
U
tr
___a______D-________tr_____Qreliry_.lo-i!g_'.tlgglq!iIe_s_qlgp_qrl!_c_lgp)__________q_______!___
tr
D
tl
!
tr Earaches or ear pain
tr Hearingloss
n
tr
___a______F_______tr____Aqcfg_elt_to_teeth
D
fl
tl
tr
tr Broken jaw
! Mouthbreather
tr
tr
________q_______E___
D
!
tr
tr
___A______qr________D_____c_q{_o_pglrgll!_dl_rl,g-ygy____ ______q_______E_____
tr
D
U Mouth goes to one side when fully opened !
tr
D
D
tr Clench teeth during day
D
tr
-__A______!r________D_____9r-n9_ts_e_t!'_gyt'r'_g_liq!!_________ ______!_______q_____
f]
tr
tr Difficult or painful to swallow (food, pills, fluid) tr
n
tr
!
tr Generally sore mouth
tJ
tr
___q______!_
tl
D
D
tr
tr
tr
Painful or burning tongue
Painful or sore teeth
n
tr
tr
U
---q-_____F________n____l_e_e_t!r_991!!_tile_!9_Lo_!_9I_qo_tg__ ________E_______!___
D
D
tr Dental infections or abcessed teeth
tr
tr
D
D
tr Gum disease or bteeding gums
tr
n
___A______q_______n____fgs_tg_s_919q!9l,_s_9!9l,9_e_qEt_ely__________________q_______!___
f1
tr
tr
D
n
D
mouth
Surgery
tr
tr
Metal taste in
Oral
___a______qr________o____gis_{es_!q9t[9r!Lqc_t9g_
tr
tr
___-!_______!_______
ft
tr
D
tr
tr
n
tr
D
ft
n
U
F____p_e_qt_e!_9r.t9ggy_qrl
tr
tr
tr
tr
D
tr
D
n
!
tr
TJ
tr
U
D
u
u
General Anesthesia
Caps or crowns on teeth
D
Teeth ground on by Dentist
Orthodontia (braces)
Signature:
Date:
Gopyright O 1976 National Capital Genter for Craniofacial Pain. All rights reserved.
Page 7
5. Head, Neck and Face Symptoms (continued)
Have
Never Have
Had Had
tr
tr
fi
D
Left
Now
Have
n
E
Ghewtobacco
Neck injury or operation
___a______F________tr_____r_ryi_s_t!!e_I_e_Sgg_ig\U_nqrtel
tr
tl
tr
tr
r-r
LJ
D
tr
D
tr
tr
tl
tr-l
L-J
Tr
r.-.l
n
n
u
tr
tr
!
tr
tr
tr
!
tr
tr
T
n
u
n
tr
D
n
norse
Twisting neck quickly causes pain
Lumps or swelling in neck
Chronic stiff neck
Neckaches
Whiptash neck injury
Cervical traction neck
collar
Chronic dry cough
Throat hoarse when you don't have a cold
Throat sore when you don,t have a cold
D
D
D
U
n
E
tr
T-t
tr
tr
tr
tr
tr
n
!
u
tr
ft
U
tr
D
tr
D
-----____Y
Chronic feeting of foreign object (chicken bone)
in throat
Numbness of shoulder, arms, hands, fingers
Shoulder Pain
D
tr_
tl
_!
D
tr Scoliosis (curvature of the spine)
!
D Backaches
---a-----_!_______tr_____u_re_qssllqs_le!s!!
n
tr
tl Inabitity to sit stiil for prolonged time
tr
tr
tr
Right
r-t
u
tl
r-'l
tr
LJ
L]
T-t
n
LJ
_________A_______!__
tr
tr
when did you first experience lhe pain for which you are now seeking help? Date:
7. What do YOU think is the cause of your pain?
8. under what circumstences did the pain begin? (please check all that apply)
[] Accident at work
! Other Reasons Or Circumstances
n Accident at home
(Please Explain)
tr Other accident
tr At work, but not an accident
D Following surgery
fl Following illness
tr Pain just began, can't relate it to anything
6.
your specilic complaints? From what symptoms do you most desire relief? List from most important to least important.
9. Wha t are
1)
4',i,
2)
5)
3)
6)
Signature:
Date:
Copyright O 1976 National Capital Center for Craniofacial Pain. All rights reserved.
Page 8
10. Practllloners: Since your pain condition began, which of the following people have you seen for treatment
and pain relief?
Have Now
Have
Seeing
fl Acupuncturist
f
DlAllergisttrDNeurosurgeon
Seen
Seen
I
___!_______!___Ate:tlrqsl919g!_s_t____
D Cardiologist (Heart)
n
trXChiropractor!trOptometrist
Now
Seeing
I
Neurologist (Nervous System)
-__F_________!___.[r_gitt9!is_t___
!
D Opthalmologist (Eyes)
n
D
D
f
Dentist
Dermatologist (Skin)
tl
D
D
tr
Osteopathic physician
pediatrician (Chitdren)
tr
n
!
f,
I
tr
Endocrinologist
Faith Healer
General and/or Family
!
I
tr
[
I
D
Proctologist
Psychiatrist
Psychotogist
______I_L1c_tt_c_e_l]w_s_'giql_________ ____!________!___l_foj9!q9r_s_t____
!
n
D
!
U Gynecologist/Obstetrician
A Hypnotist
___!_______Q___llle_,tfq.!_lYt_e_ojgt-qe_ltLtJ9ll'_s_t)___
tr
! Naturopath
D
[
Surgeon(General)
Other(Specify)
______
11. How long have you been bothered by this problem?
(a)
years
Headaches per week
12. Are your symptoms worse:
Yes
tr
n
n
O
D
n
(b)
months
(c)
weeks
Neckaches per week
No
n Upon arising in the morning
E At work
D At the end of your work day
n At school
tr At home
D when with your children
yes
D
tr
D
n
tr
tr
No
tl
tr
D
t]
n
D
When with your parents
When with your in-laws
When yawning
In the Fall or Winter
Hay Fever Season
Rainy weather
Date:
@NTINUE TO NEXT PAGE
Copyrlght O 1976 Natlonal Capltal Center for Craniofaclal Pain. All rights reserved.
yes_ No-
13. Does any other member of your famity have the same or similar problem?
14.
(a)
Page 9
lf yes, explain
How many times have you been operated on for the pain?
(b) -zero
Did the operation(s) bring relief from pain?
-one -two -three -four
_Yes _No
oi rnore times
-five -six
15. (a) How many times have you had nerve blocks (injections) for the pain?
_six or more times
(b) -ze(o
Did any of
these
injections
bring
relief
from
pain?
the
-one -two -three -four -five
16.
_Yes _No
How often do you take medicine for reliel of the pain?
Seldom
Often
Often
17. What-Never
do you do-Very
that starts the pain, or makes it worse?
-Fairly
-Very
-Regularly
18. what activity or medicine decreases the pain or brings relief?
19. Do you have days when the pain is so bad that you spend the day in bed?
yes_
No_
20. Personal History: Mark an X in the appropriate box indicating that you:
Yes
No
- fl
. I
]- f
r n
D I
[ tr
! n
! tr
tr tr
tr tr
Drink 2 or more alcoholic drinks per day?
Smoke tobacco?
Use Marijuana?
Have troubre stopping the breeding from even a smail cut?
Are handicapped in any way?
Considered committing suicide?
use, or have used heroin, cocaine, LSD, uppers, downers, or similar drugs?
Been told by some Doctors that your pain was imaginary or,,all in your
head,,?
Have had Doctors or nurses act as if you were faking the pain?
Are bringing suit or expect to sue because of your pain?
Signature:--Date:
Copyright O 1976 Nationat Capital Center for Graniofacial Pain. Alt rights reserved.
Page 10
21. please describe any other pertinenl information, symptom, disorder, etc., not previously covered.
22. What one vital plece of informatlon are you holdlng back?
23. List the treatments you have had for this problem:
Doctor
Treatment
Signature:
Date:
Gopyright O 1976 National Gapital Center tor Graniotacial Pain. All rights reserved.
page
11
PLEASE READ THESE
TNSTBUCTIONS VERY CAREFULLY. WE WANT YOU TO INDTCATE ON THE
DRAWINGS
ON THE NEXT PAGE EXACTLY WH.E^RE YOUR PAIN IS, AND HOW MUCH PAIN
YOU FEEL. EEAO ALL INSTRUC.
IIONS BEFORE YOU DO ANYTHING.
1' Mark on the drawing the exact spot(s) where your pain slarts a solid dot (.). lf the pain
starts al that spol
and radiates elsewhere (travels to another pirt oi your face, head or
of
arrows from the
spot where il starts to where it ends. lf it is a wn6te area that hurts, ""tli'oia*
"'tine
shai.e in that
area with a pencil.
2' Next to the places on the drawing where you showed pain,. put.gl. "E" if the pain is exlernat (skin
surface); if
i'i". tt the pain is dotr inrernar
l["r3."'" is inlernal (inside the-body) mirk rhii wiin'in
.it"in"[ -!,[
3
"n,]
Af ter you have
shown where the pain is, and where it travels lo, we want to know how much pain you
feel. Mark
the painful area with lhe loltowing symbols:
.
E
I
PAIN
EXTERNAL PAIN
INTERNAL PAIN
3
.
I
IIII
MoDERATE PAIN
SEVERE PAIN
SHOOTTNG PAtN
NUMBNESS
Before you begin to do anything to the drawings on the next page, look at
the exampte and read the description
of whal it means so that you will understanil p;rfecfly whar you are to do.
SAMPLE OF HOW TO INDICATE PAIN
LEFT
Area of severe pain at
crown of head
Moderate pain in left
temple
\=-
\t*lI
Pain is internal
'o
Pain starts in front of
ear and radiates to
temple
Numbness of left cheek
Pain is on surface of
skin
Pain begins at back of
neck and radiates
upward
t
-1t
t
t
o
Signature:
Date:
Copyright @ 1976 National Capital Center for Craniofacial pain. All rights reserved.
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Headache, Neckache and Facial Pain Diagnosis

Transcription

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