Orofacial Pain/Discomfort Survey Please enable JavaScript in your browser to complete this form. – Step 1 of 4Section 1: Your Facial Symptoms1. In which areas do you experience pain or discomfort? (Tick all that apply) *1. Lips: upper or lower2. Teeth: Front upper or lower3. Teeth: Back upper or lower4. Gums: upper or lower5. Palate6. Tongue7. Floor of mouth8. Throat9. Forehead10. Headache11. Eyes12. Nose and sinus13. Ears14. Face15. Jaw joint16. Lower border of jaw2. On average, what percentage of your day are you in pain or discomfort? (Select only one) *0% – 25%26% – 50%51% – 75%76% – 100%3. How many days per week do you experience these symptoms? (Select only one) *1 day2–3 days4–5 days6–7 days (Daily)4. How would you rate your facial pain or discomfort over the last week on a scale of 0 to 10? (0 is none, 10 is the worst imaginable) * None Worst Imaginable012345678910 5. Symptom Description (Part A): How would you describe the feeling? (Tick all that apply) *SharpStabbingDull acheThrobbingBurning6. Symptom Description (Part B): Would you describe this as an "altered sensation," including any of the following? (Tick all that apply) *NumbnessPins and needlesTinglingIncreased sensitivity to touch (even light touch feels uncomfortable)None of the aboveNextSection 2: Other Body Symptoms and Health7. Do you experience pain or discomfort in other parts of your body? (Tick all that apply) *1. Neck pain2. Upper back pain3. Chest pain4. Arm pain5. Leg pain6. Stomach pain7. Knee pain8. Foot pain9. Other joint pain10. Other pain8. How many days per week do you experience this "other" body pain or discomfort? (Select only one) *1 day2–3 days4–5 days6–7 days (Daily)9. How would you rate this "other" body pain or discomfort on a scale of 0 to 10? * None Worst Imaginable01234567891010. Have you been diagnosed with any of the following conditions? (Tick all that apply) *AnxietyDepressionHeadache disordersIrritable Bowel Syndrome (IBS)Vulvodynia (pain, burning and discomfort in the vulva that cannot be linked to a specific cause)FibromyalgiaME/CFS (Chronic Fatigue Syndrome)POTS (Postural Orthostatic Tachycardia Syndrome)Hypermobility (Ehlers-Danlos etc.)Sleep problems (Insomnia, Sleep Apnoea)Chronic FatigueOtherPlease write your other diagnosis below.NextSection 3: Healthcare Experience11. Which health practitioners have you consulted regarding your pain or discomfort? (Tick all that apply) *General Medical Practitioner (GP)General Dental PractitionerMedical Specialist: Pain SpecialistMedical Specialist: NeurologistMedical Specialist: RheumatologistDental Specialist: Oral and Maxillofacial SurgeonDental Special Interest: Orofacial PainOtherPlease write your other health practitioners you consulted below.12. Have you received an official diagnosis for your pain or discomfort? (Select only one) *YesNo13. If you answered "Yes" above, what is your current diagnosis?14. Do you agree with this diagnosis? (Select only one) *YesNoNot Applicable15. How long did it take (or has it taken so far) to get a diagnosis? (Select only one)Less than 6 months6 months to 1 year1–2 years2–5 yearsMore than 5 years16. Before your current diagnosis, how many incorrect diagnoses did you receive? (Select only one)01-23-5More than 517. How satisfied were you with the treatment options provided to you? (Select only one)Very UnsatisfiedUnsatisfiedNeutralSatisfiedVery Satisfied (Part orofacial "altered 18. Do you feel your medical or dental practitioner was knowledgeable in how to treat your specific symptoms? (Select only one)YesNo19. How would you rate your practitioner's knowledge of your specific symptoms on a scale of 1 to 10? Not at all Extremely Knowledgeable012345678910NextSection 4: Future Improvements20. Do you believe there is a significant problem with how orofacial pain and discomfort are recognized and managed in Australia and New Zealand (ANZ)? (Select only one) *YesNo21. Is there a need for a dedicated training program for health professionals to manage orofacial pain in a team-based (multidisciplinary) way? (Select only one) *YesNo22. Any other comments regarding your experience?Your sex *MaleFemaleYour Age Range *10-3031-5051-70> 70Submit
