TMJ Spa/Assessment Form

Name* This field is required.

First Name

Last Name

Address* This field is required.

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Email* This field is required.

example@example.com

Phone Number* This field is required.

Please enter a valid phone number.

DOB:* This field is required.

Date

Dentist Name:* This field is required.

First Name

Last Name

Dentist Phone Number:* This field is required.

Please enter a valid phone number.

IN YOUR OWN WORDS PLEASE EXPLAIN WHY YOU ARE HERE* This field is required.

DATE PROBLEM BEGAN* This field is required.

AGE PROBLEM BEGAN* This field is required.

PREVIOUS FACIAL INJURY? * This field is required.

WHEN WAS THE INJURY? * This field is required.

PLEASE GIVE DETAILS OF THE INJURY

ORTHODONTICS | RESULTS:

Good

Fair

Poor

Bite ADJUSTMENT | RESULTS:

Good

Fair

Poor

PHYSICAL THERAPY | RESULTS:

Good

Fair

Poor

TMJ SPLINT | RESULTS:

Good

Fair

Poor

TMJ ARTHROSCOPIC SURGERY | RESULTS:

Good

Fair

Poor

TMJ OPEN JOINT SURGERY | RESULTS:

Good

Fair

Poor

TMJ PROSTHETIC REPLACEMENT | RESULTS:

Good

Fair

Poor

MEDICATIONS TAKEN IN THE PAST FOR TMJ

CURRENT MEDICATIONS FOR TMJ

PLEASE INDICATE WHERE YOU ARE HAVING PAIN* This field is required.

INDICATE ON THE FOLLOWING SCALE HOW SEVERE YOUR PAIN IS THE MAJORITY OF THE TIME* This field is required.

PLEASE INDICATE WHERE YOU ARE HAVING PAIN* This field is required.

INDICATE ON THE FOLLOWING SCALE HOW SEVERE YOUR PAIN IS THE MAJORITY OF THE TIME* This field is required.

IS THE PAIN* This field is required.

CONSTANT

INTERMITTENT

DOES IT HURT TO MOVE YOUR JAW?* This field is required.

Yes

DOES IT HURT TO TO CHEW?* This field is required.

Yes

DOES THE PAIN/PROBLEM LIMIT YOUR FUNCTION?* This field is required.

Yes

WHEN IS THE PAIN WORSE?

MORNING

AFTERNOON

EVENING

Other

DOES ANYTHING YOU DO MAKE THE PAIN WORSE?

DOES ANYTHING YOU DO MAKE THE PAIN BETTER?

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

DO YOU HAVE OR HAVE YOU HAD ANY OF THE FOLLOWING?* This field is required.

LIST OTHER MEDICAL PROBLEMS

THE PAIN IS HAVING THIS EFFECT ON MY LIFE.* This field is required.