Do you have jaw joint pain, clinically known as temporomandibular joint (TMJ) pain? No Yes Is the pain? Mild Moderate Severe
Do you have TMJ noises when you open and close your mouth? No Yes Are the noises? Clicking Popping Grinding Are the noises? Mild Moderate Severe Is the pain in the TMJ on the Left Right Are the TMJ noises on the Left Right
When did your jaw joint problems (i.e., pain, noises, headache) begin? Age Year What started your jaw joint problems? Injury Disease UnknownExplain:
Have you had previous TMJ surgery? No Yes How many operations? Right TMJ Left TMJ Have your jaw alignment or bite changed? No Yes How much change? Mild Moderate Severe
Do you get headaches? Yes No Are the headaches: Mild Moderate Severe Are your headaches worse in the:MorningAfternoonEveningNight No Difference How many headaches do you get? a week a month Are they: Occasional Frequent Constant
Where do the headaches occur? Left Forehead Right ForeheadLeft Temple Right Temple Back of the Head Top of Head Behind Left Eye Behind Right Eye Do you have pain elsewhere? Neck Shoulder or Back pain Is the pain: Mild Moderate Severe Do you clench and/or grind your teeth at night? (Yes/No)During the day? No Yes Is your clenching/grinding: Mild Moderate Severe
Do you get earaches? No Yes On which side? Left Right Are they: Mild Moderate Severe Do they occur: Occasionally Moderately Frequently Continuously
Do you get ringing in your ears? No Yes Is the ringing: Mild Moderate Severe Does it occur: Occasionally Moderately Frequently Continuously
Do you get lightheadedness or dizziness?NoYes Is it Mild Moderate Severe Does it occur: Occasionally Moderately Frequently Continuously
Do you suffer from depression? No Yes Are you under treatment for depression? No Yes Do you have problems with other body joints? No Yes Please list the other joints: Type a label