TMJ Evaluation

TMJ Evaluation Form
Name *

First Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Email *
example@example.com
Phone Number *
Please enter a valid phone number.
AGE *
IN YOUR OWN WORDS PLEASE EXPLAIN WHY YOU ARE HERE *
DATE PROBLEM BEGAN *
AGE PROBLEM BEGAN *
PREVIOUS FACIAL INJURY? *
WHEN WAS THE INJURY? *
PLEASE GIVE DETAILS OF THE INJURY
PLEASE CHECK WHETHER YOU HAVE HAD ANY OF THE FOLLOWING
ORTHODONTICS | RESULTS:

Good Fair Poor
WHEN?
Bite ADJUSTMENT | RESULTS:

Good Fair Poor
WHEN?
PHYSICAL THERAPY | RESULTS:

Good Fair Poor
WHEN?
TMJ SPLINT | RESULTS:

Good Fair Poor
WHEN?
TMJ ARTHROSCOPIC SURGERY | RESULTS:

Good Fair Poor
WHEN?
TMJ OPEN JOINT SURGERY | RESULTS:

Good Fair Poor
WHEN?
TMJ PROSTHETIC REPLACEMENT | RESULTS:

Good Fair Poor
WHEN?
MEDICATIONS TAKEN IN THE PAST FOR TMJ
CURRENT MEDICATIONS FOR TMJ
PLEASE INDICATE WHERE YOU ARE HAVING PAIN *

1 2 3 4 5 6
INDICATE ON THE FOLLOWING SCALE HOW SEVERE YOUR PAIN IS THE MAJORITY OF THE TIME *

1

2

3

4

5

6

7

8

9

10

1 is NO PAIN, 10 is SEVERE PAIN
PLEASE INDICATE WHERE YOU ARE HAVING PAIN *

1 2 3 4 5 6
INDICATE ON THE FOLLOWING SCALE HOW SEVERE YOUR PAIN IS THE MAJORITY OF THE TIME *

1

2

3

4

5

6

7

8

9

10

1 is NO PAIN, 10 is SEVERE PAIN
IS THE PAIN *

CONSTANT INTERMITTENT
DOES IT HURT TO MOVE YOUR JAW? *

Yes No
DOES IT HURT TO TO CHEW? *

Yes No
DOES THE PAIN/PROBLEM LIMIT YOUR FUNCTION? *

Yes No
IF SO, HOW?
WHEN IS THE PAIN WORSE?

MORNING AFTERNOON EVENING OTHER TIME
DOES ANYTHING YOU DO MAKE THE PAIN WORSE?
WHAT?
DOES ANYTHING YOU DO MAKE THE PAIN BETTER?
WHAT?
WHAT OTHER DOCTORS OR HEALTH CARE ASSOCIATES HAVE YOU SEEN REGARDING THIS PAIN/PROBLEM?
DOES YOUR JAW EVER LOCK OPEN?

OPEN CLOSED
HOW HAS THIS BEEN TREATED?
CAN YOU DO ANYTHING TO PREVENT OR TREAT THIS?
DO YOU GRIND OR GRIT YOUR TEETH?

Yes No
DO YOU HAVE OR HAVE YOU HAD ANY OF THE FOLLOWING? *
LIST OTHER MEDICAL PROBLEMS
THE PAIN IS HAVING THIS EFFECT ON MY LIFE. *

1

2

3

4

5

6

7

8

9

10

1 is NO EFFECT, 10 is CANNOT FUNCTION AT ALL
Should be Empty:

TMJ Evaluation Form

PLEASE CHECK WHETHER YOU HAVE HAD ANY OF THE FOLLOWING