Language
English (US)
TMJ Evaluation Form
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
DOB:
*
-
Month
-
Day
Year
Date
Dentist Name:
*
First Name
Last Name
Dentist Phone Number:
*
Please enter a valid phone number.
IN YOUR OWN WORDS PLEASE EXPLAIN WHY YOU ARE HERE
*
DATE PROBLEM BEGAN
*
AGE PROBLEM BEGAN
*
PREVIOUS FACIAL INJURY?
*
Please Select
No
Yes
WHEN WAS THE INJURY?
*
PLEASE GIVE DETAILS OF THE INJURY
PLEASE CHECK WHETHER YOU HAVE HAD ANY OF THE FOLLOWING
ORTHODONTICS | RESULTS:
Good
Fair
Poor
WHEN?
Bite ADJUSTMENT | RESULTS:
Good
Fair
Poor
WHEN?
PHYSICAL THERAPY | RESULTS:
Good
Fair
Poor
WHEN?
TMJ SPLINT | RESULTS:
Good
Fair
Poor
WHEN?
TMJ ARTHROSCOPIC SURGERY | RESULTS:
Good
Fair
Poor
WHEN?
TMJ OPEN JOINT SURGERY | RESULTS:
Good
Fair
Poor
WHEN?
TMJ PROSTHETIC REPLACEMENT | RESULTS:
Good
Fair
Poor
WHEN?
MEDICATIONS TAKEN IN THE PAST FOR TMJ
CURRENT MEDICATIONS FOR TMJ
PLEASE INDICATE WHERE YOU ARE HAVING PAIN
*
1
2
3
4
5
6
INDICATE ON THE FOLLOWING SCALE HOW SEVERE YOUR PAIN IS THE MAJORITY OF THE TIME
*
NO PAIN
1
2
3
4
5
6
7
8
9
SEVERE PAIN
10
1 is NO PAIN, 10 is SEVERE PAIN
PLEASE INDICATE WHERE YOU ARE HAVING PAIN
*
1
2
3
4
5
6
INDICATE ON THE FOLLOWING SCALE HOW SEVERE YOUR PAIN IS THE MAJORITY OF THE TIME
*
NO PAIN
1
2
3
4
5
6
7
8
9
SEVERE PAIN
10
1 is NO PAIN, 10 is SEVERE PAIN
IS THE PAIN
*
CONSTANT
INTERMITTENT
DOES IT HURT TO MOVE YOUR JAW?
*
Yes
No
DOES IT HURT TO TO CHEW?
*
Yes
No
DOES THE PAIN/PROBLEM LIMIT YOUR FUNCTION?
*
Yes
No
IF SO, HOW?
WHEN IS THE PAIN WORSE?
MORNING
AFTERNOON
EVENING
OTHER TIME
DOES ANYTHING YOU DO MAKE THE PAIN WORSE?
WHAT?
DOES ANYTHING YOU DO MAKE THE PAIN BETTER?
WHAT?
WHAT OTHER DOCTORS OR HEALTH CARE ASSOCIATES HAVE YOU SEEN REGARDING THIS PAIN/PROBLEM?
DOES YOUR JAW EVER LOCK OPEN?
OPEN
CLOSED
HOW HAS THIS BEEN TREATED?
CAN YOU DO ANYTHING TO PREVENT OR TREAT THIS?
DO YOU GRIND OR GRIT YOUR TEETH?
Yes
No
DO YOU HAVE OR HAVE YOU HAD ANY OF THE FOLLOWING?
*
Please Select
SINUS PROBLEMS
HEARING CHANGES
STRESSFUL JOB
SENSITIVE TEETH
RINGING IN EARS
MARITAL PROBLEMS
PERIODONTAL DISEASE
DIZZINESS
TROUBLE SLEEPING
HEADACHES
SHOULDER PAIN
ULCERS
MIGRAINES
ARTHRITIS
NERVOUS STOMACH
NECK ACHE
SKIN DISEASES
ALLERGIES
EAR ACHE
DEPRESSION
OTHERS
LIST OTHER MEDICAL PROBLEMS
THE PAIN IS HAVING THIS EFFECT ON MY LIFE.
*
NO EFFECT
1
2
3
4
5
6
7
8
9
CANNOT FUNCTION AT ALL
10
1 is NO EFFECT, 10 is CANNOT FUNCTION AT ALL
Submit
Should be Empty: