Occlusal / Temporomandibular Joint Examination Patient Questionnaire
Name
*
First Name
Last Name
Chief Complain/ Main Concern?
*
When did your Jaw Symptoms or Discomfort start?
*
Month/ Year
PLEASE CHECK YES OR NO TO THE FOLLOWING QUESTIONS:
Are you aware of clenching your teeth during the day?
*
Yes
No
Have you ever had orthodontic treatment?
*
Yes
No
Have you ever had periodontal disease (pyorrhea)?
*
Yes
No
Have you ever been told that you grind your teeth during your sleep?
*
Yes
No
Do you have any pain or soreness around your eyes, ears or other parts of your face?
*
Yes
No
Do you have missing back teeth?
*
Yes
No
Do you ever have Headaches/ Migraine?
*
Yes
No
Do you frequently have neck aches or stiff neck muscles?
*
Yes
No
Do your jaw muscles become tired frequently?
*
Yes
No
Do you have difficulty in opening your mouth wide?
*
Yes
No
Do you have difficulty in swallowing?
*
Yes
No
Have your ever received a severe blow to the side of your head or jaw?
*
Yes
No
Have you ever had pain in your jaw joint?
*
Yes
No
Have you ever had problems with your ears, such as ringing or change of hearing?
*
Yes
No
Do you ever hear grating sounds from your jaw joint?
*
Yes
No
Do you ever hear clicking or popping sounds from your jaw joint?
*
Yes
No
Are you presently in any pain from your jaw joint or muscles?
*
Yes
No
Does pain or discomfort from your jaw joint interfere with your work or activities?
*
Yes
No
Do you feel you need treatment for this problem?
*
Yes
No
Do you have a problem with insomnia?
*
Yes
No
Are you taking any tranquilizers, hypnotics, muscle relaxants or anti-depressants?
*
Yes
No
Do you smoke cigarettes, cigars or a pipe?
*
Yes
No
Do you have any problems with eating or chewing?
*
Yes
No
Has your jaw ever locked (can't open or can't close) or slipped out of place?
*
Have you ever had an injury to your neck (whiplash)?
*
Yes
No
Do you suffer from frequent neck pain?
*
Yes
No
Does your neck ever make clicking, grating, or popping noises or movements?
*
Yes
No
Does your head or neck ever get stuck momentarily in a position so you cannot move it?
*
Yes
No
Is your neck pain worse in waking?
*
Yes
No
Do you have pain or numbness in your arms, fingers or hands?
*
Yes
No
Do you have painful sensations or numbness in the head, neck or shoulder?
*
Yes
No
Is your sleep disturbed by pain of the head and neck region?
*
Yes
No
Are your daily activities or routine disturbed by pain of the head and neck region?
*
Yes
No
Have you ever had a traumatic injury?
*
Yes
No
Type of Injury
Injury to jaw
Injury to neck
Injury to head
Injury to spine
Oral Symptoms or Habits
Jaws clenched upon waking
Clenching during sleep
Grinding during sleep
Clenching while awake
Muscle fatigue
Gingiva bleeding
Facial Swelling
Other
Type of balance problems
Vertigo (dizziness)
Fainting
Other
Hearing Problems
Yes
No
Type of hearing problems
Ringing
Popping/whooshing awakening
Hearing level changes
Other
Ringing location
Right
Left
Ringing pitch
High
Low
Popping/whooshing location
Right
Left
Hearing level changes location
Right
Left
Is present stress higher than usual?
*
Yes
No
Overall feeling with discomfort today from 1 -10
*
1 = no discomfort - 10 = highest discomfort
Are you wearing an appliance now? If yes, what type?
Submit
Should be Empty: