M. JEFFREY MORTON, D.M.D., P.A.

520 STOKES ROAD • ROUTE 541   IRONSTONE VILLAGE • BUILDING C   MEDFORD, NEW JERSEY 08055 OFFICE: (609)953-0050

232 CHESTER AVENUE  MOORESTOWN, NEW JERSEY 08057 OFFICE: (856)778-1666

Name____________________________

Patient's Physician:__________

date:________

Muscle + Joint CLINICAL EXAMINATION

R L X Sore XX Pain   XXX   Spasm

Pain

1.

Vertex

(R)

(L)

2.

Occipital

(R)

(L)

3.

Preauricular

(R)

(L)

4.

Auricular

(R)

(L)

5.

Upper Back

(R)

(L)

6.

Middle Back

(R)

(L)

7.

Lower Back

(R)

(L)

8.

Scapula Area

(R)

(L)

9.

Supraorbital

(R)

(L)

10.

Cervical Region

(R)

(L)

11.

Shoulder

(R)

(L)

12.

Arm

(R)

(L)

13.

Fingers

(R)

(L)

14.

Chest

(R)

(L)

Muscle Examination (tenderness and pain on palpation)

1.

Temporal:

a.

Anterior fibers

(R)

(L)

b.

Middle fibers

(R)

(L)

c.

Posterior fibers

(R)

(L)

2.

Masseter:

a.

Zygoma

(R)

(L)

b.

Body

(R)

(L)

(R)

(L)

c.

Lateral surface of angle of mandible

3.

Interior pterygoid:

insertion

(R)

(L)

4.

External pterygoid:

insertion

(R)

(L)

5.

Sternocleidomastoid:

a.

Origin

(R)

(L)

b.

Body

(R)

(L)

c.

Insertion

(R)

(L)

6.

Trapezius:

a.

Origin

(R)

(L)

b.

Body

(R)

(L)

c.

Insertion

(R)

(L)

7.

Posterior cervicals

(R)

(L)

8.

Mylohyoid

(R)

(L)

9.

Coronoid process

(R)

(L)

10.

Hypertrophy of any muscle

Widest interincisal opening ______mm.

11.

Other areas

Deviation from straight-vertical

a.

Crepitation

(R)

(L)

b.

Rubbing

(R)

(L)

opening-and-closing movements

c.

Sagittal opening click:

immediate

(R)

(L)

intermediate

(R)

(L)

full opening

(R)

(L)

d.

Sagittal closing click:

immediate

(R)

(L)

intermediate

(R)

(L)

terminal closure

(R)

Audible click:

(R)

(L)

Primary Complaints__________________________________

Pt.                  date:

Pain symptoms

1.

Date of onset -- (R)____________ (L)____________

2.

Area of onset____________

3.

Type -- lancinating, peroxysmal, dull, superficial, deep

4.

Quality -- burning, aching

5.

Frequency____________

6.

Duration -- constant, intermittent

7.

Period of greatest intensity____________

8.

Status of pain -- increased, decreased, unchanged

9.

Onset -- abrupt, gradual

a.

tearing

b.

blurring

c.

vomiting

10.

Disappearance -- abrupt, gradual

11.

Factors alleviating pain____________

12.

Longest free period____________

13.

Triggering devices -- eating, yawning, speaking, singing, shouting

14.

Pain in specific teeth____________

15.

Additional pain information_____________________________

Oral Symptoms (other than pain)

Previous TMJ Treatment and Results ________________________________

1.

Jaws clenched upon awakening

2.

Clenching and grinding during sleep

3.

Clenching and grinding during waking hours

4.

Muscle fatigue____________

5.

Gingival bleeding and swelling

6.

Facial swelling____________

Vertigo, Syncope, Meniere's Disease Vascular Diseases and Blood Dyscrasias

Traumatic Disorders and Skull Fractures

To TMJ -- (R)          (L)

(date)________________________

To other head areas

Headaches and Head Pain (location, character, frequency and duration)

Migraine (physician)

Rheumatoid arthritis

Neuralgias

Scleroderma

Medication

Bone Dyscrasias

External traumatic arthritis

Type of Drug

Infectious arthritis

Allergy

Osteoarthritis

Orthopedic

Endocrine - female patients with temporomandibular joint syndrome seem to be more disposed to hypothyroidism. In order to establish this deficiency, the

patient is asked these questions:

E.N.T. Symptoms

a.

Do your nails break easily?

b.

Is your skin dry?

Epidemic parotitis

Sinusitis

c.

Do you tire easily?

Middle ear infection

Cysts

d.

Does the cold weather bother you?

Nasopharyngeal Conditions

Polyps

Nutritional state

Osteomyelitis

Family History of Similar Conditions

Ear Symptoms

1.

Tinnitus -- (R)          (L)

2.

Popping or shooshing noises on opening and closing -- (R)          (L)

3.

Stuffiness of ears -- (R)          (L)

4.

Changes in hearing ability -- (R)          (L)

Additional Information (mandibular deformity)