dcbia-surveys

<div class="row"> <div class="panel panel-success"> <div class="panel-body"> <div class="panel-heading"> <h1 class="panel-title">Please read each question and respond accordingly. For each of the questions below circle only one response.</h1> </div> <div class="input-group"> <span class="input-group-addon">Id</span> <input type="string" class="form-control" placeholder="Anonymized Patient id (required)" aria-describedby="basic-addon3" ng-model="formData.patientId" ng-readonly="editFields"> </div> <div class="input-group"> <span class="input-group-addon">Date</span> <input type="text" class="form-control" placeholder="0.0" aria-describedby="basic-addon3" ng-model="formData.date" readonly> </div> </div> </div> <div class="panel panel-default"> <div class="panel-heading"> <h3 class="panel-title">Would you say your health in general is excellent, very good, good, fair or poor?</h3> </div> <div class="panel-body"> <div class="input-group"> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.generalHealth" value="0"> </span> <label class="form-control" >N/A</label> </div> <div class="input-group"> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.generalHealth" value="1"> </span> <label class="form-control" >Excellent</label> </div> <div class="input-group"> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.generalHealth" value="2"> </span> <label class="form-control" >Very good</label> </div> <div class="input-group"> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.generalHealth" value="3"> </span> <label class="form-control" >Good</label> </div> <div class="input-group"> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.generalHealth" value="4"> </span> <label class="form-control" >Fair</label> </div> <div class="input-group"> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.generalHealth" value="5"> </span> <label class="form-control" >Poor</label> </div> </div> </div> <br> <div class="panel panel-default"> <div class="panel-heading"> <h3 class="panel-title">Would you say your oral health in general is excellent, very good, good, fair or poor?</h3> </div> <div class="panel-body"> <div class="input-group"> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.generalOralHealth" value="0"> </span> <label class="form-control" >N/A</label> </div> <div class="input-group"> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.generalOralHealth" value="1"> </span> <label class="form-control" >Excellent</label> </div> <div class="input-group"> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.generalOralHealth" value="2"> </span> <label class="form-control" >Very good</label> </div> <div class="input-group"> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.generalOralHealth" value="3"> </span> <label class="form-control" >Good</label> </div> <div class="input-group"> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.generalOralHealth" value="4"> </span> <label class="form-control" >Fair</label> </div> <div class="input-group"> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.generalOralHealth" value="5"> </span> <label class="form-control" >Poor</label> </div> </div> </div> <div class="panel panel-default"> <div class="panel-heading"> <h3 class="panel-title">Have you had pain in the face, jaw, temple, in front of the ear or in the ear in the past month?</h3> </div> <div class="panel-body"> <div class="input-group"> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.painFaceJawTemple" value="1"> </span> <label class="form-control" >Yes</label> </div> <div class="input-group"> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.painFaceJawTemple" value="0"> </span> <label class="form-control" >No</label> </div> </div> </div> <div class="panel panel-default"> <div class="panel-heading"> <h3 class="panel-title">How many years ago did your facial pain begin for the first time?</h3> </div> <div class="panel-body"> <div class="input-group"> <input type="number" class="form-control" aria-describedby="basic-addon1" ng-model="formData.beginPainYears"> <span class="input-group-addon" id="basic-addon1">Years</span> </div> </div> </div> <div class="panel panel-default"> <div class="panel-heading"> <h3 class="panel-title">How many months ago did your facial pain begin for the first time?</h3> </div> <div class="panel-body"> <div class="input-group"> <input type="number" class="form-control" aria-describedby="basic-addon1" ng-model="formData.beginPainMonths"> <span class="input-group-addon" id="basic-addon1">Months</span> </div> </div> </div> <div class="panel panel-default"> <div class="panel-heading"> <h3 class="panel-title">Is your facial pain persistent, recurrent or was it only a one-time problem?</h3> </div> <div class="panel-body"> <div class="input-group"> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.facialPainPersistentRecurrentOneTime" value="0"> </span> <label class="form-control" >N/A</label> </div> <div class="input-group"> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.facialPainPersistentRecurrentOneTime" value="1"> </span> <label class="form-control" >Persistent</label> </div> <div class="input-group"> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.facialPainPersistentRecurrentOneTime" value="2"> </span> <label class="form-control" >Recurrent</label> </div> <div class="input-group"> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.facialPainPersistentRecurrentOneTime" value="3"> </span> <label class="form-control" >One time</label> </div> </div> </div> <div class="panel panel-default"> <div class="panel-heading"> <h3 class="panel-title">Have you ever gone to a physician, dentist, chiropractor or other health professional for facial ache or pain?</h3> </div> <div class="panel-body"> <div class="input-group"> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.goneToHealthProfessional" value="0"> </span> <label class="form-control" >N/A</label> </div> <div class="input-group"> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.goneToHealthProfessional" value="1"> </span> <label class="form-control" >No</label> </div> <div class="input-group"> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.goneToHealthProfessional" value="2"> </span> <label class="form-control" >Last six months</label> </div> <div class="input-group"> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.goneToHealthProfessional" value="3"> </span> <label class="form-control" >More than six months</label> </div> </div> </div> <div class="panel panel-default"> <div class="panel-heading"> <h3 class="panel-title">How would you rate your facial pain on a 0 to 10 scale at the present time, that is right now, where 0 is "no pain" and 10 is "pain as bad as could be"?</h3> </div> <div class="panel-body"> <div class="input-group"> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.facialPainRate" value="0"> </span> <label class="form-control" >0</label> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.facialPainRate" value="1"> </span> <label class="form-control" >1</label> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.facialPainRate" value="2"> </span> <label class="form-control" >2</label> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.facialPainRate" value="3"> </span> <label class="form-control" >3</label> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.facialPainRate" value="4"> </span> <label class="form-control" >4</label> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.facialPainRate" value="5"> </span> <label class="form-control" >5</label> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.facialPainRate" value="6"> </span> <label class="form-control" >6</label> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.facialPainRate" value="7"> </span> <label class="form-control" >7</label> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.facialPainRate" value="8"> </span> <label class="form-control" >8</label> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.facialPainRate" value="9"> </span> <label class="form-control" >9</label> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.facialPainRate" value="10"> </span> <label class="form-control" >10</label> </div> </div> </div> <div class="panel panel-default"> <div class="panel-heading"> <h3 class="panel-title">In the past six months, how intense was your worst pain rated on a 0 to 10 scale where 0 is "no pain" and 10 is "pain as bad as could be"?</h3> </div> <div class="panel-body"> <div class="input-group"> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.facialPainIntensity" value="0"> </span> <label class="form-control" >0</label> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.facialPainIntensity" value="1"> </span> <label class="form-control" >1</label> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.facialPainIntensity" value="2"> </span> <label class="form-control" >2</label> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.facialPainIntensity" value="3"> </span> <label class="form-control" >3</label> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.facialPainIntensity" value="4"> </span> <label class="form-control" >4</label> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.facialPainIntensity" value="5"> </span> <label class="form-control" >5</label> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.facialPainIntensity" value="6"> </span> <label class="form-control" >6</label> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.facialPainIntensity" value="7"> </span> <label class="form-control" >7</label> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.facialPainIntensity" value="8"> </span> <label class="form-control" >8</label> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.facialPainIntensity" value="9"> </span> <label class="form-control" >9</label> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.facialPainIntensity" value="10"> </span> <label class="form-control" >10</label> </div> </div> </div> <div class="panel panel-default"> <div class="panel-heading"> <h3 class="panel-title">In the past six months, on the average, how intense was your pain rated on a 0 to 10 scale where 0 is "no pain" and 10 is "pain as bad as could be"? [That is, your usual pain at times you were experiencing pain].</h3> </div> <div class="panel-body"> <div class="input-group"> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.facialPainAverageIntensity" value="0"> </span> <label class="form-control" >0</label> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.facialPainAverageIntensity" value="1"> </span> <label class="form-control" >1</label> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.facialPainAverageIntensity" value="2"> </span> <label class="form-control" >2</label> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.facialPainAverageIntensity" value="3"> </span> <label class="form-control" >3</label> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.facialPainAverageIntensity" value="4"> </span> <label class="form-control" >4</label> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.facialPainAverageIntensity" value="5"> </span> <label class="form-control" >5</label> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.facialPainAverageIntensity" value="6"> </span> <label class="form-control" >6</label> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.facialPainAverageIntensity" value="7"> </span> <label class="form-control" >7</label> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.facialPainAverageIntensity" value="8"> </span> <label class="form-control" >8</label> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.facialPainAverageIntensity" value="9"> </span> <label class="form-control" >9</label> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.facialPainAverageIntensity" value="10"> </span> <label class="form-control" >10</label> </div> </div> </div> <div class="panel panel-default"> <div class="panel-heading"> <h3 class="panel-title">About how many days in the last six months have you been kept from your usual activities (work, school or housework) because of facial pain?</h3> </div> <div class="panel-body"> <div class="input-group"> <span class="input-group-addon">Days</span> <input type="number" class="form-control" placeholder="Days" aria-describedby="basic-addon3" ng-model="formData.daysKeptFromUsualActivities"> </div> </div> </div> <div class="panel panel-default"> <div class="panel-heading"> <h3 class="panel-title">In the past six months, how much has facial pain interfered with your daily activities rated on a 0 to 10 scale where 0 is "no interference" and 10 is "unable to carry on any activities"?</h3> </div> <div class="panel-body"> <div class="input-group"> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.facialPainInterferedDailyActivities" value="0"> </span> <label class="form-control" >0</label> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.facialPainInterferedDailyActivities" value="1"> </span> <label class="form-control" >1</label> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.facialPainInterferedDailyActivities" value="2"> </span> <label class="form-control" >2</label> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.facialPainInterferedDailyActivities" value="3"> </span> <label class="form-control" >3</label> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.facialPainInterferedDailyActivities" value="4"> </span> <label class="form-control" >4</label> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.facialPainInterferedDailyActivities" value="5"> </span> <label class="form-control" >5</label> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.facialPainInterferedDailyActivities" value="6"> </span> <label class="form-control" >6</label> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.facialPainInterferedDailyActivities" value="7"> </span> <label class="form-control" >7</label> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.facialPainInterferedDailyActivities" value="8"> </span> <label class="form-control" >8</label> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.facialPainInterferedDailyActivities" value="9"> </span> <label class="form-control" >9</label> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.facialPainInterferedDailyActivities" value="10"> </span> <label class="form-control" >10</label> </div> </div> </div> <div class="panel panel-default"> <div class="panel-heading"> <h3 class="panel-title">In the past six months, how much has facial pain changed your ability to take part in recreational, social and family activities where 0 is "no interference " and 10 is "extreme change"?</h3> </div> <div class="panel-body"> <div class="input-group"> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.facialPainChangeRecreationalSocialFamilyActivities" value="0"> </span> <label class="form-control" >0</label> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.facialPainChangeRecreationalSocialFamilyActivities" value="1"> </span> <label class="form-control" >1</label> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.facialPainChangeRecreationalSocialFamilyActivities" value="2"> </span> <label class="form-control" >2</label> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.facialPainChangeRecreationalSocialFamilyActivities" value="3"> </span> <label class="form-control" >3</label> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.facialPainChangeRecreationalSocialFamilyActivities" value="4"> </span> <label class="form-control" >4</label> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.facialPainChangeRecreationalSocialFamilyActivities" value="5"> </span> <label class="form-control" >5</label> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.facialPainChangeRecreationalSocialFamilyActivities" value="6"> </span> <label class="form-control" >6</label> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.facialPainChangeRecreationalSocialFamilyActivities" value="7"> </span> <label class="form-control" >7</label> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.facialPainChangeRecreationalSocialFamilyActivities" value="8"> </span> <label class="form-control" >8</label> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.facialPainChangeRecreationalSocialFamilyActivities" value="9"> </span> <label class="form-control" >9</label> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.facialPainChangeRecreationalSocialFamilyActivities" value="10"> </span> <label class="form-control" >10</label> </div> </div> </div> <div class="panel panel-default"> <div class="panel-heading"> <h3 class="panel-title">In the past six months, how much has facial pain changed your ability to work including housework) where 0 is "no interference " and 10 is "extreme change"?</h3> </div> <div class="panel-body"> <div class="input-group"> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.facialPainChangedAbilityToWork" value="0"> </span> <label class="form-control" >0</label> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.facialPainChangedAbilityToWork" value="1"> </span> <label class="form-control" >1</label> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.facialPainChangedAbilityToWork" value="2"> </span> <label class="form-control" >2</label> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.facialPainChangedAbilityToWork" value="3"> </span> <label class="form-control" >3</label> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.facialPainChangedAbilityToWork" value="4"> </span> <label class="form-control" >4</label> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.facialPainChangedAbilityToWork" value="5"> </span> <label class="form-control" >5</label> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.facialPainChangedAbilityToWork" value="6"> </span> <label class="form-control" >6</label> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.facialPainChangedAbilityToWork" value="7"> </span> <label class="form-control" >7</label> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.facialPainChangedAbilityToWork" value="8"> </span> <label class="form-control" >8</label> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.facialPainChangedAbilityToWork" value="9"> </span> <label class="form-control" >9</label> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.facialPainChangedAbilityToWork" value="10"> </span> <label class="form-control" >10</label> </div> </div> </div> <div class="panel panel-default"> <div class="panel-heading"> <h3 class="panel-title">Have you ever had your jaw lock or catch so that it won't open all the way?</h3> </div> <div class="panel-body"> <div class="input-group"> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.jawLockCatch" value="1"> </span> <label class="form-control" >Yes</label> </div> <div class="input-group"> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.jawLockCatch" value="0"> </span> <label class="form-control" >No</label> </div> </div> </div> <div class="panel panel-info"> <div class="panel-body"> <div class="alert alert-info" role="alert"> If no problem opening all the way continue <a ng-click="goToScroll('question15')" href="">here</a> </div> </div> </div> <div class="panel panel-default"> <div class="panel-heading"> <h3 class="panel-title">Was this limitation in jaw opening severe enough to interfere with your ability to eat?</h3> </div> <div class="panel-body"> <div class="input-group"> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.jawLockLimitationToEat" value="1"> </span> <label class="form-control" >Yes</label> </div> <div class="input-group"> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.jawLockLimitationToEat" value="0"> </span> <label class="form-control" >No</label> </div> </div> </div> <div class="panel panel-default" id="question15"> <div class="panel panel-default"> <div class="panel-heading"> <h3 class="panel-title">Does your jaw click or pop when you open or close your mouth or when chewing?</h3> </div> <div class="panel-body"> <div class="input-group"> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.jawClickChewing" value="1"> </span> <label class="form-control" >Yes</label> </div> <div class="input-group"> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.jawClickChewing" value="0"> </span> <label class="form-control" >No</label> </div> </div> </div> <div class="panel panel-default"> <div class="panel-heading"> <h3 class="panel-title">Does your jaw make a grating or grinding noise when it opens and closes or when chewing?</h3> </div> <div class="panel-body"> <div class="input-group"> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.jawGratingGrinding" value="1"> </span> <label class="form-control" >Yes</label> </div> <div class="input-group"> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.jawGratingGrinding" value="0"> </span> <label class="form-control" >No</label> </div> </div> </div> <div class="panel panel-default"> <div class="panel-heading"> <h3 class="panel-title">Have you been told, or do you notice that you grind your teeth or clench your jaw while sleeping at night?</h3> </div> <div class="panel-body"> <div class="input-group"> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.grindTeethClenchWhileSleeping" value="1"> </span> <label class="form-control" >Yes</label> </div> <div class="input-group"> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.grindTeethClenchWhileSleeping" value="0"> </span> <label class="form-control" >No</label> </div> </div> </div> <div class="panel panel-default"> <div class="panel-heading"> <h3 class="panel-title">During the day, do you grind your teeth or clench your jaw?</h3> </div> <div class="panel-body"> <div class="input-group"> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.duringDayGrindTeethClenchJaw" value="1"> </span> <label class="form-control" >Yes</label> </div> <div class="input-group"> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.duringDayGrindTeethClenchJaw" value="0"> </span> <label class="form-control" >No</label> </div> </div> </div> <div class="panel panel-default"> <div class="panel-heading"> <h3 class="panel-title">Does your jaw ache or feel stiff when you wake up in the morning?</h3> </div> <div class="panel-body"> <div class="input-group"> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.jawAcheOrStiffMorning" value="1"> </span> <label class="form-control" >Yes</label> </div> <div class="input-group"> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.jawAcheOrStiffMorning" value="0"> </span> <label class="form-control" >No</label> </div> </div> </div> <div class="panel panel-default"> <div class="panel-heading"> <h3 class="panel-title">Do you have noises or ringing in your ears?</h3> </div> <div class="panel-body"> <div class="input-group"> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.noisesOrRingingEars" value="1"> </span> <label class="form-control" >Yes</label> </div> <div class="input-group"> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.noisesOrRingingEars" value="0"> </span> <label class="form-control" >No</label> </div> </div> </div> <div class="panel panel-default"> <div class="panel-heading"> <h3 class="panel-title">Does your bite feel uncomfortable or unusual?</h3> </div> <div class="panel-body"> <div class="input-group"> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.biteUncomfortable" value="1"> </span> <label class="form-control" >Yes</label> </div> <div class="input-group"> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.biteUncomfortable" value="0"> </span> <label class="form-control" >No</label> </div> </div> </div> </div> <div class="panel panel-default"> <div class="panel-heading"> <h3 class="panel-title">Do you have rheumatoid arthritis, lupus, or other systemic arthritic disease?</h3> </div> <div class="panel-body"> <div class="input-group"> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.systemicArthriticDisease" value="1"> </span> <label class="form-control" >Yes</label> </div> <div class="input-group"> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.systemicArthriticDisease" value="0"> </span> <label class="form-control" >No</label> </div> </div> </div> <div class="panel panel-default"> <div class="panel-heading"> <h3 class="panel-title">Do you know of anyone in your family who has had any of these diseases?</h3> </div> <div class="panel-body"> <div class="input-group"> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.knowAnyoneInFamilyWithDiseases" value="1"> </span> <label class="form-control" >Yes</label> </div> <div class="input-group"> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.knowAnyoneInFamilyWithDiseases" value="0"> </span> <label class="form-control" >No</label> </div> </div> </div> <div class="panel panel-default"> <div class="panel-heading"> <h3 class="panel-title">Have you had or do you have any swollen or painful joint(s) other than the joints close to your ears (TMJ)?</h3> </div> <div class="panel-body"> <div class="input-group"> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.swollenJointsCloseToEars" value="1"> </span> <label class="form-control" >Yes</label> </div> <div class="input-group"> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.swollenJointsCloseToEars" value="0"> </span> <label class="form-control" >No</label> </div> </div> </div> <div class="panel panel-info"> <div class="panel-body"> <div class="alert alert-info" role="alert"> If no swollen or painful joints continue <a ng-click="goToScroll('question17a')" href="">here</a> </div> </div> </div> <div class="panel panel-default"> <div class="panel-heading"> <h3 class="panel-title">Is this a persistent pain which you have had for at least one year?</h3> </div> <div class="panel-body"> <div class="input-group"> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.persistentPainAtLeastOneYear" value="1"> </span> <label class="form-control" >Yes</label> </div> <div class="input-group"> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.persistentPainAtLeastOneYear" value="0"> </span> <label class="form-control" >No</label> </div> </div> </div> <div class="panel panel-default" id="question17a"> <div class="panel-heading"> <h3 class="panel-title">Have you had a recent injury to your face or jaw?</h3> </div> <div class="panel-body"> <div class="input-group"> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.recentInjuryJawFace" value="1"> </span> <label class="form-control" >Yes</label> </div> <div class="input-group"> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.recentInjuryJawFace" value="0"> </span> <label class="form-control" >No</label> </div> </div> </div> <div class="panel panel-info"> <div class="panel-body"> <div class="alert alert-info" role="alert"> If no recent injuries continue <a ng-click="goToScroll('question18')" href="">here</a> </div> </div> </div> <div class="panel panel-default"> <div class="panel-heading"> <h3 class="panel-title">Did you have jaw pain before the injury?</h3> </div> <div class="panel-body"> <div class="input-group"> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.painBeforeInjury" value="1"> </span> <label class="form-control" >Yes</label> </div> <div class="input-group"> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.painBeforeInjury" value="0"> </span> <label class="form-control" >No</label> </div> </div> </div> <div class="panel panel-default" id="question18"> <div class="panel-heading"> <h3 class="panel-title">During the last six months have you had a problem with headaches or migraines?</h3> </div> <div class="panel-body"> <div class="input-group"> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.lastSixMonthsProblemsWithHeadachesMigraines" value="1"> </span> <label class="form-control" >Yes</label> </div> <div class="input-group"> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.lastSixMonthsProblemsWithHeadachesMigraines" value="0"> </span> <label class="form-control" >No</label> </div> </div> </div> <div class="panel panel-default" id="question18"> <div class="panel-heading"> <h3 class="panel-title">What activities does your present jaw problem prevent or limit you from doing?</h3> </div> <div class="panel-body"> <div class="input-group"> <span class="input-group-addon"> <input type="checkbox" aria-label="..." ng-model="formData.problemOrPreventChewing"> </span> <label class="form-control" >Chewing</label> </div> <div class="input-group"> <span class="input-group-addon"> <input type="checkbox" aria-label="..." ng-model="formData.problemOrPreventDrinking"> </span> <label class="form-control" >Drinking</label> </div> <div class="input-group"> <span class="input-group-addon"> <input type="checkbox" aria-label="..." ng-model="formData.problemOrPreventExercising"> </span> <label class="form-control" >Exercising</label> </div> <div class="input-group"> <span class="input-group-addon"> <input type="checkbox" aria-label="..." ng-model="formData.problemOrPreventEatingHardFoods"> </span> <label class="form-control" >Eating Hard Foods</label> </div> <div class="input-group"> <span class="input-group-addon"> <input type="checkbox" aria-label="..." ng-model="formData.problemOrPreventEatingSoftFoods"> </span> <label class="form-control" >Eating Soft Foods</label> </div> <div class="input-group"> <span class="input-group-addon"> <input type="checkbox" aria-label="..." ng-model="formData.problemOrPreventSmilingLaughing"> </span> <label class="form-control" >Smiling/laughing</label> </div> <div class="input-group"> <span class="input-group-addon"> <input type="checkbox" aria-label="..." ng-model="formData.problemOrPreventSexualActivity"> </span> <label class="form-control" >Sexual activity</label> </div> <div class="input-group"> <span class="input-group-addon"> <input type="checkbox" aria-label="..." ng-model="formData.problemOrPreventCleaningTeethOrFace"> </span> <label class="form-control" >Cleaning teeth or face</label> </div> <div class="input-group"> <span class="input-group-addon"> <input type="checkbox" aria-label="..." ng-model="formData.problemOrPreventYawning"> </span> <label class="form-control" >Yawning</label> </div> <div class="input-group"> <span class="input-group-addon"> <input type="checkbox" aria-label="..." ng-model="formData.problemOrPreventSwallowing"> </span> <label class="form-control" >Swallowing</label> </div> <div class="input-group"> <span class="input-group-addon"> <input type="checkbox" aria-label="..." ng-model="formData.problemOrPreventTalking"> </span> <label class="form-control" >Talking</label> </div> <div class="input-group"> <span class="input-group-addon"> <input type="checkbox" aria-label="..." ng-model="formData.problemOrPreventHavingUsualFaceAppearance"> </span> <label class="form-control" >Having your usual facial appearance</label> </div> </div> </div> <div class="panel panel-default"> <div class="panel-heading"> <h3 class="panel-title">In the last month, how much have you been distressed by...</h3> </div> <div class="panel-body"> <div class="row"> <div class="col-md-4"> <label class="form-control" >Headaches</label> </div> <div class="col-md-8"> <div class="input-group"> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedHeadaches" value="0"> </span> <label class="form-control" >0</label> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedHeadaches" value="1"> </span> <label class="form-control" >1</label> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedHeadaches" value="2"> </span> <label class="form-control" >2</label> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedHeadaches" value="3"> </span> <label class="form-control" >3</label> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedHeadaches" value="4"> </span> <label class="form-control" >4</label> </div> </div> </div> <div class="row"> <div class="col-md-4"> <label class="form-control" >Loss of sexual interest or pleasure</label> </div> <div class="col-md-8"> <div class="input-group"> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedLossSexualInterest" value="0"> </span> <label class="form-control" >0</label> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedLossSexualInterest" value="1"> </span> <label class="form-control" >1</label> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedLossSexualInterest" value="2"> </span> <label class="form-control" >2</label> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedLossSexualInterest" value="3"> </span> <label class="form-control" >3</label> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedLossSexualInterest" value="4"> </span> <label class="form-control" >4</label> </div> </div> </div> <div class="row"> <div class="col-md-4"> <label class="form-control" >Faintness or dizziness</label> </div> <div class="col-md-8"> <div class="input-group"> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedFaintnessDizziness" value="0"> </span> <label class="form-control" >0</label> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedFaintnessDizziness" value="1"> </span> <label class="form-control" >1</label> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedFaintnessDizziness" value="2"> </span> <label class="form-control" >2</label> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedFaintnessDizziness" value="3"> </span> <label class="form-control" >3</label> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedFaintnessDizziness" value="4"> </span> <label class="form-control" >4</label> </div> </div> </div> <div class="row"> <div class="col-md-4"> <label class="form-control" >Pains in the heart or chest</label> </div> <div class="col-md-8"> <div class="input-group"> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedPainHeartChest" value="0"> </span> <label class="form-control" >0</label> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedPainHeartChest" value="1"> </span> <label class="form-control" >1</label> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedPainHeartChest" value="2"> </span> <label class="form-control" >2</label> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedPainHeartChest" value="3"> </span> <label class="form-control" >3</label> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedPainHeartChest" value="4"> </span> <label class="form-control" >4</label> </div> </div> </div> <div class="row"> <div class="col-md-4"> <label class="form-control" >Feeling low in energy or slowed down</label> </div> <div class="col-md-8"> <div class="input-group"> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedLowEnergy" value="0"> </span> <label class="form-control" >0</label> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedLowEnergy" value="1"> </span> <label class="form-control" >1</label> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedLowEnergy" value="2"> </span> <label class="form-control" >2</label> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedLowEnergy" value="3"> </span> <label class="form-control" >3</label> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedLowEnergy" value="4"> </span> <label class="form-control" >4</label> </div> </div> </div> <div class="row"> <div class="col-md-4"> <label class="form-control" >Thoughts of death or dying</label> </div> <div class="col-md-8"> <div class="input-group"> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedThoughtsOFDeathDying" value="0"> </span> <label class="form-control" >0</label> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedThoughtsOFDeathDying" value="1"> </span> <label class="form-control" >1</label> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedThoughtsOFDeathDying" value="2"> </span> <label class="form-control" >2</label> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedThoughtsOFDeathDying" value="3"> </span> <label class="form-control" >3</label> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedThoughtsOFDeathDying" value="4"> </span> <label class="form-control" >4</label> </div> </div> </div> <div class="row"> <div class="col-md-4"> <label class="form-control" >Poor appetite</label> </div> <div class="col-md-8"> <div class="input-group"> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedPoorAppetite" value="0"> </span> <label class="form-control" >0</label> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedPoorAppetite" value="1"> </span> <label class="form-control" >1</label> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedPoorAppetite" value="2"> </span> <label class="form-control" >2</label> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedPoorAppetite" value="3"> </span> <label class="form-control" >3</label> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedPoorAppetite" value="4"> </span> <label class="form-control" >4</label> </div> </div> </div> <div class="row"> <div class="col-md-4"> <label class="form-control" >Crying easily</label> </div> <div class="col-md-8"> <div class="input-group"> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedCryingEasily" value="0"> </span> <label class="form-control" >0</label> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-model="formData.lastMonthDistressedCryingEasily" value="1"> </span> <label class="form-control" >1</label> <span class="input-group-addon"> <input type="radio" aria-label="..." ng-mod