TMJ Questionnaire
Name
*
First Name
Last Name
Responsible Party Name
*
First Name
Last Name
I. General Information
How would you rate your physical health?
*
Good
Fair
Poor
How would you rate your emotional health?
*
Good
Fair
Poor
Are you currently under the care of a physician?
*
Yes
No
Have you ever been seriously ill?
*
Yes
No
Have you been hospitalized in the past 5 years?
*
Yes
No
Have you ever had a major operation?
*
Yes
No
Women: Are you pregnant?
*
Yes
No
N/A
Has there been any change in your general health in the last year?
*
Yes
No
Has there been a major weight loss, without dieting, in recent months?
*
Yes
No
Worried about receiving medical/dental treatment?
*
Yes
No
Marital Status
*
Single
Married
Divorced
Separated
Widowed
Please list the number of children you have and their ages
Occupation
Chief Complaint
Do you know what caused you to have this pain/issue?
Did anything different happen to you about the time your problem happened or got bad enough for you to seek care? For example: change at work/school, divorce in family, increase in activities/stress?
II. Craniofacial Symptoms of the Head, Neck and Face
Fill in the appropriate response square indicating whether or not you currently have, or previously had, the following conditions or symptoms, and identify which side, right side R of L where appropriate. If both sides are involved, mark right and left sides.
Bleeding gums and/or gum disease?
*
Yes
No
Crowns on teeth and/or caps?
*
Yes
No
Do you chew gum regularly?
*
Yes
No
Do you feel that your bite closed?
*
Yes
No
Do you feel that your bite closed?
*
Yes
No
Do you feel that there is not enough room for your tongue?
*
Yes
No
Missing back teeth with no replacement?
*
Yes
No
Oral Surgery?
*
Yes
No
Orthodontic treatment?
*
Yes
No
Periodontal disease (Pyrrohea)?
*
Yes
No
Sore or painful teeth?
*
Yes
No
Teeth badly worn?
*
Yes
No
Teeth have been ground down by dentist?
*
Yes
No
Teeth feel very loose?
*
Yes
No
Teeth extracted within the past three years?
*
Yes
No
TMJ (jaw joint) treatment?
*
Yes
No
Treated for a bad bite?
*
Yes
No
Wisdom teeth removed?
*
Yes
No
Do you have frequent canker sores or cold sores?
*
Yes
No
A. Craniofacial Pain
Do you have generalized facial pain?
*
Yes
No
On which side is there constant or recurring pain?
*
Left
Right
Both
None
Does the pain or discomfort disturb your sleep?
*
Yes
No
Would you describe the pain as a dull, aching sensation?
*
Yes
No
Would you describe the pain as stabbing, sharp, severe sensation?
*
Yes
No
Do you suffer from chronic headaches?
*
Yes
No
Do you ever have migraine headaches?
*
Yes
No
Do you have tension headaches?
*
Yes
No
Headaches in right or left temple?
*
Yes
No
Headaches in the back of the head?
*
Yes
No
Do you take any medication for headaches?
*
Yes
No
Are there times when you notice that the pain or problems are less or gone completely?
*
Yes
No
Do you have pain in teeth on awakening?
*
Yes
No
Do your teeth hurt from clenching or chewing?
*
Yes
No
Does your jaw ache when you chew?
*
Yes
No
Does your jaw hurt when you open wide or take a big bite?
*
Yes
No
Does it now hurt to open wide?
*
Yes
No
Do you have ear pain?
*
Yes
No
Do you have pain in front of the ears?
*
Yes
No
Is the degree of pain same in morning as evenings?
*
Yes
No
Do you have chronic stiff neck?
*
Yes
No
Do you have neckaches (neck pain)?
*
Yes
No
Have you ever had chronic shoulder or back pain?
*
Yes
No
When are your symptoms worse?
*
Upon rising in the morning
At work
At the end of the work day
At home
At school
Before bed
Have you ever been treated for pain?
*
Yes
No
Have you ever had injections or nerve blocks for pain?
*
Yes
No
Did any of the injections bring relief from pain?
*
Yes
No
Have you ever been operated on to relieve pain?
*
Yes
No
Did the operation bring relief from pain?
*
Yes
No
How often do you take medicine for the relief of pain?
*
Never
Seldom (a few times a year)
Occasionally (once a month)
Often (weekly)
Frequently (daily)
B. Breathing Problems
Allergies?
*
Yes
No
Does your nose feel stuffy when you don’t have a cold?
*
Yes
No
Does your nose run when you don’t have a cold?
*
Yes
No
Sinus problems?
*
Yes
No
Do you snore?
*
Yes
No
Mouth breather?
*
Yes
No
Do you sleep well?
*
Yes
No
Do awaken frequently during the night?
*
Yes
No
How many pillows do you sleep on?
*
Do you have sleep apnea?
*
Yes
No
Do you have a CPAP machine?
*
Yes
No
Do you feel rested when you wake up in the morning?
*
Yes
No
C. Eye Problems
Pain in, around, or behind eyes?
*
Yes
No
Eyesight blurs?
*
Yes
No
Eyelid tics (twitches)?
*
Yes
No
Eyes blink excessively?
*
Yes
No
Do your eyes water most of the time (tearing)?
*
Yes
No
Do you have any vision problems during headaches/migraines?
*
Yes
No
D. Ear Problems
Earaches or ear pain?
*
Yes
No
Hearing loss?
*
Yes
No
Grating noise in ears (like sand particles)?
*
Yes
No
Itchiness in ears?
*
Yes
No
Stuffiness in ears?
*
Yes
No
Ringing, hissing, or buzzing sounds in ears?
*
Yes
No
Whooshing or throbbing sound in ears?
*
Yes
No
E. Equilibrium Problems
Do you feel lightheaded or dizzy?
*
Yes
No
Often feel like vomiting or nauseated?
*
Yes
No
F. Posture Problems
Do you have backaches?
*
Yes
No
Do you have an abnormal curvature of the spine?
*
Yes
No
Are your legs of unequal lengths?
*
Yes
No
Do you have problems sitting still for prolonged time?
*
Yes
No
Do you cradle the phone between your head and shoulders?
*
Yes
No
Does your work involve typing/word processing?
*
Yes
No
Do you wear high heels?
*
No
Seldom
Occasionally
Frequently
G. Lifestyle Problems
Are you under a lot of stress?
*
Yes
No
Do you bite your nails, tongue, or lips?
*
Yes
No
Take any mood affecting drugs or stimulants (coffee, tea, soft drinks)?
*
Yes
No
Do you exercise regularly?
*
Yes
No
Do you tire easily?
*
Yes
No
Do you usually eat breakfast?
*
Yes
No
Do you work more than 40 hours a week?
*
Yes
No
Do you overeat?
*
Yes
No
Do you chew gum?
*
Yes
No
If you chew gum, how often?
0-5% of waking hours
5-25% of waking hours
25-50% of waking hours
50-75% of waking hours
75-100% of waking hours
Stress Factors (Please choose each factor that applies to you)
Death of spouse
Major illness or injury
Major health change in family
Business management
Divorce/Separation
Pending marriage
Financial problems
Pregnancy
Career change
Fired from work
Marital reconciliation
Taking of debt
Death of a family member
New person joins family
Other
Do you use a computer for work or play video games?
*
Yes
No
H. Jaw (TMJ) Symptoms
Have you ever been treated for jaw joint problems, or facial muscle spasms?
*
Yes
No
Do you have difficulty in chewing your food?
*
Yes
No
Do you grind your teeth during the night?
*
Yes
No
Has anyone told you that you grind your teeth?
*
Yes
No
Are you aware of clenching your teeth during the day?
*
Yes
No
Are you aware of clenching your teeth during the night?
*
Yes
No
Are there times when you can’t open your mouth widely?
*
Yes
No
Do you have difficulty in opening your mouth widely?
*
Yes
No
Does it hurt to open your mouth widely?
*
Yes
No
Does your mouth go to one side when fully opened?
*
Yes
No
Has your jaw ever locked or were you unable to open or close your mouth?
*
Yes
No
Have you had pain in your jaw joint?
*
Yes
No
Do you hear sounds in your jaw joint?
*
Yes
No
Do you hear grating sounds in your jaw joint?
*
Yes
No
Do you hear or feel a clicking or popping in your jaw joint?
*
Yes
No
Does your jaw make clicking or popping sounds when you chew?
*
Yes
No
Does your jaw feel tired after a big meal?
*
Yes
No
Have you experienced numbness of shoulders, arms, hands, or fingers?
*
Yes
No
Do you have pain in your neck and/or shoulders?
*
Yes
No
Do you ever wake up with sore chewing muscles or sore teeth in the morning?
*
Yes
No
Do avoid certain foods because of your jaw issues?
*
Yes
No
I. Trauma Related Problems
Accident or trauma to face?
*
Yes
No
Accident or trauma to jaw?
*
Yes
No
Accident or trauma to head?
*
Yes
No
Have you ever received a severe blow to the side of the head or jaw?
*
Yes
No
Accident or trauma to neck?
*
Yes
No
Whiplash or neck injury?
*
Yes
No
Have you worn a cervical traction neck collar?
*
Yes
No
Has there been a strain or stretching of the jaw while yawning/chewing/opening the mouth wide?
*
Yes
No
Have you experienced a fall within the last two years?
*
Yes
No
J. Are there any other significant medical or dental problems?
If yes, please describe:
III. Practitioners
Please indicate which practitioners you have seen since your pain began for treatment and relief of pain.
Acupuncturists
*
Haven't Seen
Have Seen
Now Seeing
Allergist
*
Haven't Seen
Have Seen
Now Seeing
Anesthesiologist
*
Haven't Seen
Have Seen
Now Seeing
Cardiologist (heart)
*
Haven't Seen
Have Seen
Now Seeing
Chiropractor
*
Haven't Seen
Have Seen
Now Seeing
Dentist
*
Haven't Seen
Have Seen
Now Seeing
Dermatologist (skin)
*
Haven't Seen
Have Seen
Now Seeing
Dietician
*
Haven't Seen
Have Seen
Now Seeing
E.N.T.
*
Haven't Seen
Have Seen
Now Seeing
Endocrinologist
*
Haven't Seen
Have Seen
Now Seeing
Family Physician
*
Haven't Seen
Have Seen
Now Seeing
Gynecologist/Obstetrician
*
Haven't Seen
Have Seen
Now Seeing
Internist
*
Haven't Seen
Have Seen
Now Seeing
Neurologist
*
Haven't Seen
Have Seen
Now Seeing
Neurosurgeon
*
Haven't Seen
Have Seen
Now Seeing
Ophthalmologist (eyes)
*
Haven't Seen
Have Seen
Now Seeing
Optometrist
*
Haven't Seen
Have Seen
Now Seeing
Orthopedist (bones, joints)
*
Haven't Seen
Have Seen
Now Seeing
Orthodontist
*
Haven't Seen
Have Seen
Now Seeing
Osteopathic physician
*
Haven't Seen
Have Seen
Now Seeing
Pediatrician (children)
*
Haven't Seen
Have Seen
Now Seeing
Physical therapist
*
Haven't Seen
Have Seen
Now Seeing
Physiatrist
*
Haven't Seen
Have Seen
Now Seeing
Plastic Surgeon
*
Haven't Seen
Have Seen
Now Seeing
Psychiatrist
*
Haven't Seen
Have Seen
Now Seeing
Psychologist
*
Haven't Seen
Have Seen
Now Seeing
Radiologist
*
Haven't Seen
Have Seen
Now Seeing
Rheumatologist
*
Haven't Seen
Have Seen
Now Seeing
Surgeon
*
Haven't Seen
Have Seen
Now Seeing
Please list any other practitioners you have seen or are currently seeing:
IV. Pain Summary
Please identify your areas of pain indicating right R and/or left L that you presently or frequently experience.
Top of head
*
Left
Right
Both
Neither
Back of head
*
Left
Right
Both
Neither
Frontal headache
*
Left
Right
Both
Neither
Eye and eyebrow
*
Left
Right
Both
Neither
Temporal headache
*
Left
Right
Both
Neither
Jaw and cheek
*
Left
Right
Both
Neither
Ear and jaw joint area
*
Left
Right
Both
Neither
Toothache
*
Left
Right
Both
Neither
Front of neck and throat
*
Left
Right
Both
Neither
Side of neck
*
Left
Right
Both
Neither
Back of neck
*
Left
Right
Both
Neither
Upper thoracic of back
*
Left
Right
Both
Neither
Mid-thoracic of back
*
Left
Right
Both
Neither
Lower back
*
Left
Right
Both
Neither
Back of the shoulder
*
Left
Right
Both
Neither
Front of shoulder
*
Left
Right
Both
Neither
Back of arm
*
Left
Right
Both
Neither
Front of arm
*
Left
Right
Both
Neither
Upper chest area
*
Left
Right
Both
Neither
Describe your pain
*
Dull
Throbbing
Stabbing
Aching
Pressure
Sharp
Burning
Pulsating
Other
Does your pain radiate/travel or move from the area of initial pain?
*
Pain moves up side of head
Pain moves around back of head
Pain moves down the neck
Pain does not radiate/travel
When do you have pain?
*
Constantly
Frequently, not predictable
Frequently and predictably
Occasionally
No real pattern
How long does the pain last?
*
Less than 1 minute
1-10 minutes
Less than 1 hour
1-5 hours
6-12 hours
13-24 hours
Several days
Constant
Do you have numbness or unusual feelings or sensations in your face or jaw?
*
Yes
No
Do any of the following cause or aggravate the pain?
*
Chewing
Opening mouth wide
Talking
Playing a musical instrument
Yawning
Laughing
Singing
Other
What relieves the pain?
*
Massage of the area
Warm soaks or compresses
Holding jaw in certain positions
Pain medications
Moving or manipulating jaw
Sleep
Time
Relaxation
Heat
Other
V. Bite and Tooth Concerns
Bad Bite?
*
Yes
No
Buck teeth/overjet?
*
Yes
No
Crowding of upper teeth?
*
Yes
No
Crossbite?
*
Yes
No
Grinding (Bruxism)?
*
Yes
No
Gummy smile?
*
Yes
No
Mouth too small?
*
Yes
No
Spaces?
*
Yes
No
VI. Health Professional(s)
(Current or have seen previously)
01: Doctor Name
Reason(s) for treatment
02: Doctor Name
Reason(s) for treatment
03: Doctor Name
Reason(s) for treatment
Comments
To the best of my knowledge, all the preceding answers are true and correct. If deemed advisable, I grant permission for my physician to be contacted for information and advice. If I have any change in my health or medications that is not reported above, I will inform the doctor at my next visit.
Patient’s/Responsible Party’s Signature
*
Date
-
Month
-
Day
Year
Date
Submit
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