click to download (pdf): Salivary gland questionnaire 03232013.pdf
click to download (word .doc):  Salivary gland questionnaire 03232013.docx

see also information about: Salivary Swelling; Instructions to patients submandibular salivary stones; Sialograms and Sialography; Salivary Ultrasound

Questions:

Age:
Sex:
Occupation (if retired, what did you do before retirement):
Computer skills to use email and search the internet: yes____ no____
Please provide a brief description of the symptoms you are having that warrant a visit to the doctor for you salivary gland(s):
 
In addition to the description provided above, please add the following information (if not already present in your description) regarding A. Swelling B. Pain and C. Other information:

A.  If swelling:

What side(s), which glands (cheek=parotid gland versus under jaw= submandibular gland verus both areas)

How many years/months has it been going on?

How often does it occur:

How long (give a range) does the swelling last when it occurs (minutes/hours/days/weeks/months)

What makes it better?

What makes it worse?

Is it associated with meals?

Have you received antibiotic or steroids for it (please indicate what you received and how many times, and the most recent):

B. If pain:

What side(s), which glands (cheek versus under jaw verus both)

How many years/months has it been going on?

How long (give a range) does the swelling last when it occurs

What makes it better?

What makes it worse?

C. Other Questions

Do you have dry eyes or dry mouth? Do you use eye drops to keep your eyes moist?

Do you have an autoimmune disorder such as rheumatoid arthritis, sjogrens syndrome, SLE, thyroiditis, fibromyalgia? Have you had blood studies draw to evaluate for these disorders – and if so, what did they show?

Have you had exposure to therapeutic radiation (radioactive iodine; external beam)?

            If so, please describe when and what for:

Have you had imaging of your salivary glands and what did it show

a. CT

b. MRI

c. Ultrasound of your salivary glands

What medications are you on:

Do you have allergies and if so what are they:

Do you now or did you in past use tobacco? Please describe:

Do you have any other medical problems such as: Diabetes, hypertension, heart disease, lung disease, kidney disease, abnormal bleeding or bruising, neurologic or emotional problems: