Contact us
If you wish us to diagnose and/or treat your oromandibular dystonia, please fill in the detailed questionnaire below and email it to Dr. Kazuya Yoshida (yoshida.kazuya.ut@mail.hosp.go.jp) as an attachment or fax it to +81-75-643-4325. Alternatively, you could post it to: Department of Oral and Maxillofacial Surgery, Kyoto Medical Center, 1-1, Mukaihata-cho, Fukakusa, Fushimi-ku, Kyoto 612-8555, Japan. Please note that due to the number of inquiries we receive from patients, it might take us some time to reply. We take care to manage patients’ personal information in an appropriate manner; however, transmitting personal information over the internet carries a risk of it being lost or disclosed. This site is my own (Dr. Kazuya Yoshida). Personal questions about medical care for other physicians at the Kyoto Medical Center cannot be accepted. If you have been treated elsewhere, you should have your physician write a letter of introduction. Also, if you are on any oral medication, we ask you to bring your prescription to your initial consultation.
Oromandibular dystonia questionaire
Please fill out the following questionnaire. You can check more than one answer. If none of the example answers are applicable, please provide as much specific information as you can.
Please fill out the following questionnaire. You can check more than one answer. If none of the example answers are applicable, please provide as much specific information as you can.
Full Name:
Gender: Male ( ), Female ( )
Date of birth: year ( ), month ( ), day ( )
Address:
Phone:
Fax:
E-mail:
1. What kind of symptoms do you have?
Clenching teeth ( ), Mouth opening ( ), Lateral or frontal shifting of the jaw ( ), Tongue protrusion ( ), Contraction around the mouth ( ), Movement of the tongue ( ), Movement of the lips ( ),
Other, please describe them specifically ( )
2. What problems does your condition cause?
Can not eat ( ), Can not talk ( ), Can not open mouth ( ), Pain ( ), Difficulty in swallowing ( ), Discomfort ( ),
Other, please describe them specifically ( )
3. How long have you had the symptoms?
( ) year(s), ( ) month(s), ( ) day(s)
4. Were your symptoms triggered by something?
No ( ), Yes ( )
If yes: Dental treatment ( ), Injuries to the mouth or jaw ( ), Oral medication ( ),
Other, please describe ( )
5. What part(s) of your body is affected?
Mouth ( ), Mandible (lower jaw) ( ), Maxilla (upper jaw) ( ), Lips ( ), Cheek ( ), Neck ( ), Eyelid ( ),
Other, please describe ( )
6. When do you experience symptoms?
During speaking ( ), During eating ( ), During mouth opening ( ), During swallowing ( ), Always ( ),
Other, please describe specifically ( )
7. Is there anything that temporarily eases the symptoms?
No ( ), Yes ( ), Depends on time ( )
If yes: Putting something in my mouth ( ), Touching my jaw with my hand or fingers ( ), Touching my mouth with a handkerchief or mask ( ),
Other, please describe specifically ( )
8. Do you have symptoms when you are sleeping?
No ( ), Yes ( ), Not sure ( )
Other, please describe ( )
9. Do the symptoms change over time?
No ( ), Yes ( ), There is a difference from day to day ( )
No symptoms upon awakening ( ), The symptoms become worse from morning to night ( ),
Other, please explain specifically ( )
10. Have you ever taken psychiatric drugs? Or are you now taking them?
No ( ), Yes ( )
If yes: For ( ) year(s), ( ) month(s), ( ) day(s)
Which drug(s)? ( )
11. Have you ever been treated for another form of dystonia or muscle contraction?
No ( ), Yes ( )
If yes: Spasmodic torticollis (cervical dystonia) ( ), Blepharospasm (spasms of the eyelids) ( ), Writer's cramp (hand dystonia) ( ), Hemifacial spasm (hemifacial-cramp) ( ), Other ( )
12. Which clinical departments have you visited so far for treatment?
None ( ), Department of Neurology ( ), Dentistry ( ), Oral and Maxillofacial Surgery ( ), Neurosurgery ( ), Otolaryngology ( ), Psychiatry ( ), Acupuncture ( ), Other ( )
13. What kind of examinations have you had?
None ( ), MRI ( ), CT ( ), EMG ( ), X-ray ( ), Blood test ( ), Genetic testing ( ), Other ( )
14. Have you had your symptoms treated?
No ( ), Yes ( )
If yes: Oral medication ( ), Botulinum therapy (Botox) ( ), Acupuncture ( ), Magnetic stimulation ( ), Surgery ( ),
Other ( )
15. Do you have any other medical condition now?
No ( ), Yes ( )
If yes: what? ( )
And where were you treated? At the Department of Neurology ( ), Psychiatry ( ), Orthopedics ( ),
Psychosomatic ( ), Surgery ( ), Internal medicine ( ), Other ( )
16. Please add any other information or questions.
( )
The above data will only be used for diagnostic purposes. We take care to manage personal information in an appropriate manner. Due to the number of inquiries we receive from patients, we might have to wait for some time for a reply.