TMJ Questionnaire
Patient Name
*
How long have you experienced difficulty with your joint(s)?
*
Less than 6 months
Less than 1 year
Greater than 1 year
Do you experience popping/clicking in your jaw joint(s)?
*
Yes
No
If yes, which side?
Right
Left
Both
Do you experience headaches?
*
Yes
No
If yes, which side?
Right
Left
Both
Do you have difficulty opening or closing?
*
Yes
No
Unsure
Have you had a lock in your jaw
*
Yes
No
Unsure
If yes, was the lock open or close?
Open Lock
Close Lock
How often have you experienced the lock?
Do you get migraines?
*
Yes
No
Do you feel that you have an uneven bite that has contribute to your jaw joint problems?
*
Yes
No
If yes, explain:
Do you clench/grind your teeth at night?
*
Yes
No
Unsure
Do you chew gum, eat hard candy or ice?
*
Yes
No
Is there any history of trauma to head or face? (Auto accident, sport injury, facial impact)
*
Yes
No
If yes, explain:
Name of Medications you are currently taking for TMJ/TMD, appliances being utilized, or any other treatment you are current receiving or have received in the past (Type "N/A" if none).
*
Have you been diagnosed with fibromyalgia?
*
Yes
No
Year:
Do you drink beverages with high levels of caffeine?
*
Yes
No
If yes, how many a day?
Do you smoke or use other products that contain nicotine?
*
Yes
No
Have you had any major dental treatment in the last two years?
*
Yes
No
If yes, please mark procedure(s):
*
Oral Surgery
Periodontics
Orthodontics
Restoratice
Other
Have you ever been examined for a TMD/TMJ problem before?
*
Yes
No
If yes, what was the nature of the problem? (pain, popping/clicking, limitation of movement)
On a scale of 1-10 (with 10 being the worst pain) what is your current pain level?
*
Signature
*
Date
*
-
Month
-
Day
Year
Date
Submit
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