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Sleep Health Centre Albany Creek

Headache Prevention, Snoring, Sleep Disorders, Clenching and
Grinding, Jaw Joint Therapy, Breathe Well, Sleep Aponea

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Sleep Health

Head and Neck Pain Questionnaire

A doctor who does not take a full history and a patient who will not give enough details are in danger of misdiagnosis and poor treatment. 

Thank you for taking the time to give as much detail as possible by answering all questions.

Make an appointment at our Sleep Health Centre at Bupa Dental Albany Creek.

Patient Information
Title:
Surname:* Given Name:*
Preferred Name: Date of Birth:*
Address:* Suburb:*
Postcode:*
Ph (home):* Mobile Number:
Ph (work):
E-mail:*
Occupation:
Contact Person in Emergency: Phone:
Head and Neck Pain
What is currently your chief complaint?:
When did your problem begin?:
Did your problem begin after one of these events?:
What is the severity of your pain?:
Describe the way your pain typically feels:
What areas do you feel pain?:
If other; Describe where you feel pain:
How long does the pain typically last?:
How many days during the past month did you have the pain?:
What causes or aggravates the pain?:
Which of the following relieves the pain?:

Check any of the following that you experience:

Are you also bothered by headaches?
Headaches
Are you also bothered by headaches?

If yes, please answer the following questions;

On average, how painful are your headaches?:
Do you have headaches as often as once per week?
Do you have more than one type of headache?
Do you wake in the morning with a headache?
Do you have headaches later in the day?
Do headaches wake you from sleep?
Is there any nausea or vomiting associated with your headaches?
Are there vision changes associated with your headaches?
If yes, what kind?:
Do bright lights or loud noise make it worse?
What relieves the headache?:
Have you at any time ever been in an accident, fall, motor vehicle accident or received a "blow" or injury to any part of your face, head, neck or back?
If yes, when?:
Describe the circumstances of the injury::
Jaw Sounds
Are you aware of your jaw making sounds?

If yes, please answer the following questions;

Which side?:
Describe the nature of the sound::
When do you notice the sounds?:
Does the sound happen every time?
Do you feel that the sounds are related to your pain?
Has your jaw ever locked open?:
Date of first occurence:
If yes, can you replace the jaw to normal position yourslef?
Has your jaw ever locked closed or partially closed?:
How many times has your jaw locked open or closed during the past year?:
Do you have pain when your jaw locks open or closed?
Habits/Practices

Have you noticed any other oral habits or practices that aggravate or cause pain?

Other:

Check all of the following that apply to you:

Check all of the following that apply to you

Average Bedtime Hour:
Average Waking Time:
Do you feel that you usually eat a healthy, balanced diet

For each of the beverages listed below, write in the average number that you will drink each day:

(Cups per day)

Natural coffee:
Decaffeinated coffee:
Natural tea:
Decaffeinated tea:
Fruit juice:
Water:
Alcoholic beverage:
Soft drink:
Other:
Health Care Providers & Treatment

What types of health care providers have you seen for your problem?

Other:
Please list the names of the above health care providers::

Check all diagnostic tests and examinations that have been performed to account for your pain

There were no findings to account for my discomfort or pain
If yes, what was the diagnosis?:

Which of the following treatments have your received for your pain?

Other:
What treatment seemed to help?:
General Health Questions
Do you smoke?
If yes, how much? (packs per week):
How many years?:
How much pain relief medication do you take?:
Are you receiving or applying for disability, work cover or injury claim?
Are you taking (or supposed to be taking) any medicaine, vitamins, herbal medicines, supplements, prescribed drugs or recreational drugs?
If yes, what kind and what dose?:
Do you have reactions or allegies to drugs or medicines?
If yes, please specify:
Have you had an adverse reaction to dental or general anaesthetic?
Have you ever had any operations or surgery?
Please describe the surgery and complications, if any:
Do you ever have to stop because of pain in your chest, shortness of breath or because you are very tired when walking or taking the stairs?
Do your ankles swell during the day?
Have you unintentionally lost or gained more than 5kg in the past year?
Are you on a special diet?
(WOMEN) are you pregnant or possibly pregnant?
Is your pain affecting work/home life/financial situation?
Have you got good support from a partner/family/friend/community?

Is the pain affecting your:

Are you feeling

Are there people in your family suffering from the same condition
What do you think is causing the problem?:
Medical History

Please check the box for any condition which you have had in the past or have now.

Cardiovascular:

Haematologic:

Neurologic:

Gastointestinal:

Pulmonary:

Dermal/Musculoskeletal:

Endocrine:

Genitourinary:

Other Conditions:

Other disease, problem or condition not listed please specify here::
How did you hear about us?
Referral Source:    
Keep Informed Yes No
To receive updates and be kept informed on what is new in the practice, services and new dental techniques that may affect my next visit.
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Consent for Services

I have accurately completed this pre-clinical questionnaire to the best of my knowledge.I hereby give my authority for any treatment agreed up on by me, to be carried out by the dentists and their staff and I assume full financial responsibility for said treatment.

 

 

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