• Child TMJ Questionnaire

    In order for us to properly diagnose and treat our patients, we must have accurate background and health information on which to base our decisions. Please provide the information requested below:
  • Today's Date:
     - -
  • Sex*
  • Date of Birth*
     - -
  • Format: (000) 000-0000.
  • Patient Lives With:*
  • Format: (000) 000-0000.
  • Father's Date of Birth:
     - -
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Mother's Date of Birth:
     - -
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Is the Patient Covered By Insurance for Orthodontic Treatment?*
  • Is the Patient Covered By Insurance for TMJ Treatment?*
  • Format: (000) 000-0000.
  • Who referred you to this office for TMJ treatment?

  • INSTRUCTIONS:

    The first part of your health questionnaire is designed to help us focus upon your specific concerns. The second part of the questionnaire will allow you to provide any explanations necessary to enhance our overall understanding. Although some questions may seem somewhat “strange” or not applicable to you there is a specific reason behind each question asked. The accuracy and completeness of your answers directly affect the diagnostic decisions and treatment recommendations made on your behalf. Your confidentiality will be respected. Please give this exercise your “best effort.”

  • HEAD NECK, AND FACE SYMPTOMS:

    Please select the appropriate response indicating whether or not you currently have (current condition), previously had (previous condition), or never had the following conditions or symptoms and identify a “right side” or “left side” location where appropriate.

  • Painful or sore teeth*
  • Teeth Sensitive to hot or cold*
  • Gum disease or bleeding gums*
  • Oral surgery*
  • Wisdom teeth removed*
  • Caps or crowns on teeth*
  • Teeth ground by dentist*
  • Chew gum*
  • Have you ever had orthodontic treatment*
  • Have you ever had periodontal disease (pyorrhea)?*
  • Have you ever been treated for a bad bite?*
  • Do you have missing back teeth and no replacement?*
  • Do you feel that your bite is closed?*
  • Do you feel that there is enough room for your tongue?*
  • Are any of your teeth worn badly?*
  • Are any of your teeth very loose?*
  • Have you had teeth extracted within the last 3 years?*
  • Accident to teeth?*
  • Accident to jaws?*
  • Accident to face?*

  • PAIN

  • Do you have tension headaches?*
  • Are there time when you notice that this problem is less or gone completely?*
  • Do your teeth hurt from clenching or chewing?*
  • Does the pain or discomfort disturb your sleep?*
  • Is there constant or recurring pain?*
  • Would you describe the pain as dull, aching sensation?*
  • Would you describe the pain as a stabbing, sharp, or severe sensation?*
  • Does your jaw ache when you chew?*
  • Does your jaw hurt when you open wide or take a big bite?*
  • Do you have ear pain?*
  • Have you ever had chronic shoulder or back pain?*
  • Do you have pain in the teeth on arising?*
  • Do you have headaches in the left or right temple?*
  • Do you have headaches in the back of your head?*
  • Do you have generalized facial pain?*
  • Is the degree of pain the same in the morning as the evening*
  • Do you have a chronic stiff neck?*
  • Do you have neckaches or neck pain?*
  • Does it now hurt to open wide?*
  • Have you ever been operated on for pain?*
  • Did the operation bring you relief from pain?*
  • Did any of the injections bring relief from pain?*
  • How often do you take medicine for relief of pain?

  • TMJ SYMPTOMS

  • Can you open your mouth all the way?*
  • Does your mouth goes to one side when fully opened?*
  • Do you have numbness of the shoulder, arms, hands, or fingers?*
  • Do you have shoulder pain?*
  • Has your jaw ever locked so you were unable to open or close it?*
  • Does your jaw ever make any noise?*
  • Have you ever been treated for problems of your jaw joint or facial muscle spasms?*
  • Do you ever awaken with awareness of your teeth or jaws?*
  • Are you aware of clenching your teeth during the day?*
  • Do you have difficulty in opening your mouth widely?*
  • Do you have difficulty swallowing?*
  • Have you ever had pain in your jaw joint?*
  • Do you ever hear grating sounds from your jaw joint?*
  • Do you ever hear or feel a clicking or popping from your jaw joint?*
  • Does your jaw make clicking or popping sounds when you chew?*
  • Does your jaw feel tired after a big meal?*
  • Has anyone else ever heard you grinding your teeth in your sleep?*
  • Has anyone else ever heard you grinding your teeth during the daytime?*
  • Are you aware that you clench your teeth during the night?*
  • Does it hurt now to open wide?*
  • Does it ever hurt to open wide?*

  • EARS

  • Do you have itchiness or stuffiness in your ears?*
  • Do you have ringing, hissing, or buzzing sounds in your ears?*
  • Do you have grating noises (like sand particles) in your ears?*
  • Do you get earaches or ear pain?*
  • Have you experienced hearing loss?*
  • Do you have throbbing or whooshing sounds in your ears?*

  • BREATHING

  • Do you have alergies?*
  • Do you have sinus problems?*
  • Is your nose ever stuffed when you don't have a cold?*
  • Does your nose ever run when you don't have a cold?*
  • Do you snore?*
  • Are you a mouth breather?*

  • POSTURE

  • Do you have abnormal curvature of the spine?*
  • Do you experience backaches?*
  • Do you have unequal leg length?*
  • Are you able to sit still for a prolonged period of time?*
  • Do you cradle the phone between your head and shoulders?*
  • Does your work involve typing/word processing?*
  • Do you wear high heels?*

  • EYES

  • Do you have pain in, around, or behind your eyes?*
  • Do you experience eyelid tics or twitches?*
  • Do your eyes blink or water most of the time?*
  • Does your eyesight ever blur?*

  • EQUILIBRIUM

  • Do you ever experience dizziness or lightheadedness?*
  • Do you often feel nauseous (like vomiting) ?*

  • TRAUMA

  • Have you have ever had an accident or trauma to the head?*
  • Have you have ever had an accident or trauma to the face?*
  • Have you have ever had an accident or trauma to the jaw?*
  • Have you have ever had an accident or trauma to the neck?*
  • Have you ever had whiplash or a neck injury?*
  • Have you ever had cervical traction or a neck collar?*
  • Have you ever received a severe blow to the side of the had or jaw?*
  • Was there ever a strain or stretching of the jaw such as yawning during a dental procedure, while chewing, or opening the mouth wide?*
  • Have you ever had a broken jaw?*
  • Have you experienced a fall within the last 3 years?*

  • LIFESTYLE

  • Do you usually eat breakfast?*
  • Do you bite your nails, tongue, or lips?*
  • Do you have any mood swings affecting drugs or stimulants?*
  • Do you exercise regularly?*
  • Do you work more than 40 hours per week?*

  • MEDICAL HISTORY:

    Please select the appropriate response indicating whether or not you currently have (current condition), previously had (previous condition), or never had the following conditions or symptoms.

  • Arteriosclerosis*
  • Rheumatoid arthritis*
  • Swolen, stiff, or painful joints*
  • Osteoarthritis (neck, joints, etc.)*
  • Heart trouble*
  • Heart murmur*
  • Pains or tightness in chest*
  • Low blood pressure (hypotension)*
  • High blood pressure (hypertension)*
  • Fainting spells or feeling faint?*
  • Feel exhausted or fatigued most of the time*
  • Swollen ankles or feet*
  • Hands get cold*
  • Bruise easily*
  • Slow healing sores*
  • Muscle soreness or stiffness*
  • Had tremors*
  • Diabetes*
  • More thirsty than usual lately*
  • High or low blood sugar*
  • Sugar in urine*
  • Blood in urine*
  • Shortness of breath*
  • Use extra pillows to breathing at night*
  • Hard to concentrate or remember*
  • Difficulty falling asleep or staying asleep*
  • Frequently irritable*
  • Endocrine or hormone problems*
  • Cancer*
  • Any history of substance use or abuse*
  • Numbness of hands or arms*
  • Asthma*
  • AIDS*
  • Autoimmune disorder*
  • Hepatitis*

  • MEDICINES:

    Please select the appropriate response indicating whether you are sensitive or alergic to or are now taking any of the following medications.

  • Heart pills (Digitalis, etc.)
  • Nerve pills
  • Diet pills -diuretics
  • Pain pills (Demerol, Codeine, etc.)
  • Vitamins
  • Birth Control pills
  • Sleeping pills
  • Muscle relaxants
  • Insulin

  • FOOD ALLERGIES:

    Please select the appropriate response indicating whether you have an allergic response to any of the following foods:

  • Dairy products
  • Wheat, cereals
  • Dyes in food

  • PRACTITIONERS:

    Since your pain began, which of the following people have you seen for pain relief?

  • Acupuncturists
  • Allergist
  • Anesthesiologist
  • Cardiologist (heart)
  • Chiropractor
  • Clergyman
  • Dentist
  • Dermatologist (skin)
  • Dietician
  • Ear, nose and throat specialist
  • Endocrinologist
  • Faith healer
  • Family physician
  • Gynecologists/obstetrician
  • Hypnotist
  • Internist
  • Naturopath
  • Neurologist
  • Neurosurgeon
  • Nutritionist
  • Ophthalmologist (eyes)
  • Optometrist
  • Orthopedist (bones, joints)
  • Orthodontist
  • Physical therapist
  • Plastic surgeon
  • Proctologist
  • Psychiatrist
  • Psychologist
  • Radiologist
  • Rheumatologist
  • Surgeon
  • Should be Empty: