Symptom Survey

"*" indicates required fields

Patient Information

Name*

Date of Birth*

Symptom Discomfort Scale

Please rate the following symptoms from 0 to 10, where 0 indicates no discomfort and 10 indicates the worst discomfort imaginable.

If the symptom is not occurring, please select N/A.

Clicking*

Locking*

Grinding Noise*

Facial Pain*

Headache*

Neck Ache*

Ear Ache*

Ear Ringing*

Ear Fullness*

Dizziness*

Limited Opening*

Inability to Close*

Pain with Opening*

Pain with Chewing*

Symptom Frequency Scale

Please rate the following symptoms according to the frequency with which they occur, where 0 indicates never and 10 indicates constantly.

Clicking Frequency*

Locking Frequency*

Grinding Noise Frequency*

Facial Pain Frequency*

Headache Frequency*

Neck Ache Frequency*

Ear Ache Frequency*

Ear Ringing Frequency*

Ear Fullness Frequency*

Dizziness Frequency*

Limited Opening Frequency*

Inability to Close Frequency*

Pain Opening Frequency*

Pain Chewing Frequency*

Pain Locations

Edit each of the following images to show exactly where your pain is and how it feels.

Click the pencil to edit each image.

Pain Illustrations

Describe briefly the problem in your own words including when you feel it started and what you think may have caused the problem.

Please indicate any past treatment you have had for this problem.

Please list any medications, past and present, you have taken specifically for this problem.

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Office Hours

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TUE 9AM‑5PM
WED 9AM‑5PM
THU 9AM‑5PM
FRI 9AM‑1PM

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1110 Colvin Blvd.
Tonawanda, NY 14223

(716) 565‑0685

info@drfrancisoday.com

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