Oromandibular dystonia questionnaire
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.
( )
Please email your responses to the above questions to Dr. Kazuya Yoshida as an attachment (yoshida.kazuya.ut@mail.hosp.go.jp) or fax them to +81-75-643-4325). Alternatively, you can post them to: Department of Oral and Maxillofacial Surgery, Kyoto Medical Center, 1-1, Mukaihata-cho, Fukakusa, Fushimi-ku, Kyoto 612-8555, Japan.
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.