Orthognathic Surgery Questionnaire

Please complete this questionnaire prior to your consultation with the surgeon. Answer all questions to the best of your ability. The more accurate your responses the better the diagnosis and treatment offered.
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Please complete this questionnaire prior to your consultation with the surgeon. Answer all questions to the best of your ability. The more accurate your responses the better the diagnosis and treatment offered.

Name
1. What is the reason for your visit?
Please select all that apply
2. What would you like to improve about your facial appearance?
Please select all that apply
3. What is your impression of the type of treatment you need?
Please select all that apply
4. Have you had another surgical opinion?
5. Have you seen an orthodontist?
6. Please answer the following in relation to jaw function and previous orthodontic treatment:
YesNo
Have you had previous orthodontic treatment?
Yes
No
Did you ever wear an orthodontic functional appliance?
Yes
No
Did you ever have a roof of the mouth appliance?
Yes
No
Have you had previous jaw surgery?
Yes
No
Have you ever experienced jaw joint pain or clicking?
Yes
No
Have you ever experienced a locked jaw?
Yes
No
Have you ever experienced a dislocated jaw?
Yes
No
Have you ever wore a dental splint?
Yes
No
Do you sometimes have difficulty chewing and eating?
Yes
No
Do you have problems with your speech?
Yes
No
Do you have problems with swallowing?
Yes
No
Do you suffer from sleep apnoea?
Yes
No
7. Please answer the following questions which relate to your prior knowledge of orthognathic surgery
YesNo
Have you done any research on corrective jaw surgery?
Yes
No
Do you know anyone personally who has undergone corrective jaw surgery?
Yes
No
Are you aware of the benefits of corrective jaw surgery?
Yes
No
Are you aware of the risks of corrective jaw surgery?
Yes
No
8. Do any of the following concern you about undergoing corrective jaw surgery?
YesNo
Pain
Yes
No
Swelling
Yes
No
Being in hospital
Yes
No
Numbness
Yes
No
Undergoing a general anaesthetic
Yes
No
Not waking up from the anaesthetic
Yes
No
Drastic change in appearance
Yes
No
Other
Yes
No
9. How keen are you to proceed with jaw surgery?