Center For Facial Pain

CONSULTATION FORM

Disclaimer: This section is a way of transmitting advice based on Dr. Mitchell's training and experience. It is in no way intended as a substitute for referral to a qualified orofacial pain specialist if available.

If you request information (differential diagnoses and/or treatment suggestions) on a particular patient, please fill out the following form. Fill out only those which are pertinent to your question.

Use the last area to also ask any general questions which may not pertain to a particular case and skip the rest of the form. I will try to respond within 48 hours.

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Subject's Age:
Gender:
Problems:	Jaw Pain - Unilateral Jaw Pain - Bilateral Clicking on Opening/Closing Clicking with Catching or Momentary Closed Locking Limited Jaw Opening w/ History of Clicking Limited Jaw Opening w/o History of Clicking Jaw Locks Wide Open Unable to Occlude on Back Teeth - Episodic and Reduces With Lateral Movement of Jaw Unable to Occlude on Back Teeth - Prolonged and Slow to Resolve Frequent Headaches Toothache in Absence of Tooth or Tooth Pathology Other - Describe Below
Pain Quality:	Aching or Soreness Aching or Soreness Exacerbated with Opening or Chewing Pressure or Fullness Sharp Pain of Short Duration - Spontaneous Sharp Pain of Short Duration - Provoked by Some Stimulus Other - Describe Below
Pain Location:	Pre-auricular Area Ear Midface Along Body of Mandible Tooth or Edentulous Area Temple Infraorbital Supraorbital Other - Describe Below
Other Problem, Describe:
History of Problem:
Other Head or Neck Symptoms:	Ear Pain &/or Pressure Tinnitus Sinus or Nasal Congestion Numbness in Face Frequent Headaches Ongoing Neck Pain or Stiffness Other - Describe Below
Medical Hx and Current Meds
Habits:	Fingernail Biting Nocturnal Clenching or Bruxing Clenching During Daytime Biting on Non-Food Items Frequent Gum Chewing Frequent Use of Athletic Mouthguard Use of Soft Nightguard
Max Interincisal Opening mm:
Lateral Movement R/L mm:
Deflection on Opening:	Right Left
Reciprocal Clicking:	Right Left Right Left Right Left
Crepitus:
Tenderness to Palpation of TMJ:
Tenderness - Muscles Specify:	Right Left
Other Signs or Observations:
Questions for Dr. Mitchell:

CENTER FOR FACIAL PAIN

CONSULTATION FORM