Santa Fe Dentist Robert L Wartell, DDS - Dentistry, Sleep Apnea, Migraine, and TMJ Pain Treatment

in Santa Fe, New Mexico
Robert L. Wartell, DDS
Kristine Berg Ali, DMD
Sandraluz Gonzales, RDH
Carmen Lucero, CTA

Home

Request Newsletter Subscription

Our Commitment to You

Our Patients Tell Us

List of Services

Your First Visit

Forms

Insurance

Payment Options

Driving directions

Our Staff

Dr. Wartell Dr. Ali

Privacy Practices Notice

Consumer Information Links

Dental Implants

One Visit Crowns

TMJ Disorder

Sleep Apnea

Migraine relief

Our Hours

Emergency Care

Head and Neck Pain Questionnaire

Your name:

Your date of birth:

Your email:

As you can see, this is a complex questionnaire. The complexity is because head, neck and jaw pain are very complex problems, and require a tremendous amount of information to diagnose and treat effectively. Do your best to answer all questions as accurately as possible. Answer every question. Some questions do not require certain answer buttons - these buttons have been removed. If you do not have a listed symptom, click the "None" button.

Symptom	Where				How severe (10 is most severe)										How often				How long it lasts
	None	Right	Left	Both	1	2	3	4	5	6	7	8	9	10	Constant	Daily	Weekly	Monthly	Weeks	Days	Hours	Minutes	Seconds
Pain in front of head (Frontal)
Pain in entire head (General)
Pain in top of head (Parietal)
Pain in back of head (Occipital)
Pain in temples (Temporal)
Symptom	Where				How severe (10 is most severe)										How often				How long it lasts
	None	Right	Left	Both	1	2	3	4	5	6	7	8	9	10	Constant	Daily	Weekly	Monthly	Weeks	Days	Hours	Minutes	Seconds
Jaw pain when opening
Jaw pain when chewing
Jaw pain at rest
Jaw clicking
Jaw locking closed
Jaw locking open
Jaw popping
Symptom	Where				How severe (10 is most severe)										How often				How long it lasts
	None	Right	Left	Both	1	2	3	4	5	6	7	8	9	10	Constant	Daily	Weekly	Monthly	Weeks	Days	Hours	Minutes	Seconds
Teeth clenching
Teeth grinding
Grinding noises in jaw joints
Unable to open mouth wide
Symptom	Where				How severe (10 is most severe)										How often				How long it lasts
	None	Right	Left	Both	1	2	3	4	5	6	7	8	9	10	Constant	Daily	Weekly	Monthly	Weeks	Days	Hours	Minutes	Seconds
Blurred vision
Double vision
Eye Pain
Pain or pressure behind eyes
Extreme sensitivity to light
Symptom	Where				How severe (10 is most severe)										How often				How long it lasts
	None	Right	Left	Both	1	2	3	4	5	6	7	8	9	10	Constant	Daily	Weekly	Monthly	Weeks	Days	Hours	Minutes	Seconds
Buzzing in ears
Ear congestion
Ear pain
Hearing loss
Pain behind ear
Pain in front of ear
Frequent ear infections
Ringing in the ears
Dizziness
Symptom	Where				How severe (10 is most severe)										How often				How long it lasts
	None	Right	Left	Both	1	2	3	4	5	6	7	8	9	10	Constant	Daily	Weekly	Monthly	Weeks	Days	Hours	Minutes	Seconds
Lower back pain
Middle back pain
Upper back pain
Chronic sore throat
Feeling of object in throat
Throat pain
Difficulty swallowing
Limited movement of neck
Neck pain
Symptom	Where				How severe (10 is most severe)										How often				How long it lasts
	None	Right	Left	Both	1	2	3	4	5	6	7	8	9	10	Constant	Daily	Weekly	Monthly	Weeks	Days	Hours	Minutes	Seconds
Shoulder pain
Numbness/tingling of hands/fingers
Sciatica
Scoliosis
Swelling in neck
Swollen glands
Thyroid enlargement
Symptom	Where				How severe (10 is most severe)										How often				How long it lasts
	None	Right	Left	Both	1	2	3	4	5	6	7	8	9	10	Constant	Daily	Weekly	Monthly	Weeks	Days	Hours	Minutes	Seconds
Sinus congestion
Chronic sinusitis
Frequent snoring
Sleep apnea
Headaches
Migraine headaches
Facial pain
Fatigue
Muscle twitching
Symptom	Where				How severe (10 is most severe)										How often				How long it lasts
	None	Right	Left	Both	1	2	3	4	5	6	7	8	9	10	Constant	Daily	Weekly	Monthly	Weeks	Days	Hours	Minutes	Seconds
Tooth pain
Gum pain
Broken teeth
Missing teeth
Burning tongue
Dry mouth

Thank you for completing this form. Please continue on to any other forms we require from you after you click the Submit button.

Be sure to take a break if you need one.

We enjoy answering your questions.
For more information, please call us at 505-474-4644

Center For Dental Medicine • 2019 Galisteo St. • J2 • Santa Fe, NM 87505
(Behind Los Alamos National Bank, St. Michael's & Galisteo) Map