TMJ Questionnaire

  • TMJ Questionnaire

    If you can answer YES to the question asked, circle YES. If you have to answer NO to the question, circle NO. Please answer all questions.
  • Format: (000) 000-0000.
  • Do you have clicking, popping or grating noise in your right jaw joint?
  • Do you have clicking, popping or grating noise in your left jaw joint?
  • Has the noise recently become more pronounced?
  • Do you have pain in or around the right joint?
  • Do you have pain in or around the left joint?
  • Has the pain recently become more pronounced?
  • Is the pain worse:
  • Is this pain:
  • Does the pain sometimes feel like it is in your ear?
  • Do you think this problem has affected your hearing?
  • Does your jaw problem interfere with your normal activities?
  • Are you taking or have you taken medication for this problem?
  • Did anything occur which might be related to the onset of this problem?
  • Do you have difficulty chewing?
  • Because of:
  • Has your mouth ever locked open so you were unable to close it?
  • Have you had problems opening your mouth wide?

  • Please indicate the time sequence in which you became aware of
    the following problems (1st, 2nd, 3rd, etc.) Number only those
    which apply to you

  • Are you aware of clenching your teeth?
  • Do you grind your teeth?
  • Has there been a recent change in your lifestyle such as a change in marital status, childbirth, change of employment, death in immediate family or other stressful events?
  • Do you think nervous tension seems to affect this problem?
  • Have you had problems with other joints?
  • Have you had orthodontic treatment?
  • Have you had recent dental treatment?
  • Have you had x-rays taken for this problem?
  • Have you received previous treatment for this problem?

  • Consent

  • I understand that under the Health Insurance Portability & Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to:

    • Conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly and indirectly.
    • Obtain payment from third-party payers.
    • Conduct normal healthcare operations such as quality assessments and physician certifications.

    I have been informed by you of your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I have been given the right to review such Notice of Privacy Practices prior to signing this consent.

    I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time at the address below to obtain a current copy of the Notice of Privacy Practices.

    I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment, or healthcare operations. I also understand that you are not required to agree to my requested restrictions, but if you do agree, then you are bound to abide by such restrictions. I understand that I may revoke this consent in writing at any time, except to the extent that you have taken action relying on this consent.

  • Release and Waiver

  • Today's Date*
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