FORM FOR PATIENTS WITH A WORK RELATED INJURY
THIS FORM WILL BE USED TO PROVIDE YOUR SURGEON WITH A DETAILED RECOUNT OF YOUR INJURY. THIS FORM WILL TAKE APPROXIMATELY 10-15 MINUTES TO COMPLETE, BUT WILL PROVIDE INSIGHTFUL INFORMATION AS TO YOUR NEEDS.
Mechanism of injury (check all that apply):*
Did you lose consciousness?*
Please mark all areas where you sustained injury:*
Specific Injuries diagnosed (if known)*
Current ability to open mouth:*
Jaw movement difficulties (check all that apply):*
Current pain level (0-10 scale, 0=no pain, 10=worst imaginable):
Pain Character: Check all that apply
Does the pain interfere with sleep?
Other pain management strategies used
Immediate treatment received (check all that apply)
Medical specialists and other health providers involved in your care
Employment status before injury
Physical demands of your job (check all that apply)
Activities of Daily Living
Psychological and Social Impact
How has this injury affected your mood? (check all that apply)
Have you experienced any of the following since the injury:
Are you receiving psychological support?
This questionnaire will be reviewed by the oral and maxillofacial surgery team prior to your consultation. Please bring any relevant imaging, reports, or documentation from previous treating practitioners to your appointment.
