TMJassociates.com - TMJ Free Evaluation

1
Name* This field is required.
First Name
Last Name
2
Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
3
Email* This field is required.
example@example.com
4
Phone Number* This field is required.
Please enter a valid phone number.
5
DOB:* This field is required.
Date
Year
Month
Day
6
Dentist Name:* This field is required.
First Name
Last Name
7
Dentist Phone Number* This field is required.
Please enter a valid phone number.
8
IN YOUR OWN WORDS PLEASE EXPLAIN WHY YOU ARE HERE* This field is required.
9
DATE PROBLEM BEGAN* This field is required.
10
AGE PROBLEM BEGAN* This field is required.
11
PREVIOUS FACIAL INJURY? * This field is required.
No
Yes
12
WHEN WAS THE INJURY? * This field is required.
13
PLEASE GIVE DETAILS OF THE INJURY
14
ORTHODONTICS | RESULTS:
Good
Fair
Poor
15
WHEN?
16
Bite ADJUSTMENT | RESULTS:
Good
Fair
Poor
17
WHEN?
18
PHYSICAL THERAPY | RESULTS:
Good
Fair
Poor
19
WHEN?
20
TMJ SPLINT | RESULTS:
Good
Fair
Poor
21
WHEN?
22
TMJ ARTHROSCOPIC SURGERY | RESULTS:
Good
Fair
Poor
23
WHEN?
24
TMJ OPEN JOINT SURGERY | RESULTS:
Good
Fair
Poor
25
WHEN?
26
TMJ PROSTHETIC REPLACEMENT | RESULTS:
Good
Fair
Poor
27
WHEN?
28
MEDICATIONS TAKEN IN THE PAST FOR TMJ
29
CURRENT MEDICATIONS FOR TMJ
30
Image Field
31
PLEASE INDICATE WHERE YOU ARE HAVING PAIN* This field is required.
1
2
3
4
5
6
32
INDICATE ON THE FOLLOWING SCALE HOW SEVERE YOUR PAIN IS THE MAJORITY OF THE TIME* This field is required.
1
2
3
4
5
6
7
8
9
10
NO PAIN
SEVERE PAIN
33
Image Field
34
PLEASE INDICATE WHERE YOU ARE HAVING PAIN* This field is required.
1
2
3
4
5
6
35
INDICATE ON THE FOLLOWING SCALE HOW SEVERE YOUR PAIN IS THE MAJORITY OF THE TIME* This field is required.
1
2
3
4
5
6
7
8
9
10
NO PAIN
SEVERE PAIN
36
IS THE PAIN* This field is required.
CONSTANT
INTERMITTENT
37
DOES IT HURT TO MOVE YOUR JAW?* This field is required.
Yes
No
38
DOES IT HURT TO TO CHEW?* This field is required.
Yes
No
39
DOES THE PAIN/PROBLEM LIMIT YOUR FUNCTION?* This field is required.
Yes
No
40
IF SO, HOW?
41
WHEN IS THE PAIN WORSE?
MORNING
AFTERNOON
EVENING
Other
42
DOES ANYTHING YOU DO MAKE THE PAIN WORSE?
43
WHAT?
44
DOES ANYTHING YOU DO MAKE THE PAIN BETTER?
45
WHAT?
46
WHAT OTHER DOCTORS OR HEALTH CARE ASSOCIATES HAVE YOU SEEN REGARDING THIS PAIN/PROBLEM?
47
DOES YOUR JAW EVER LOCK OPEN?
OPEN
CLOSED
48
HOW HAS THIS BEEN TREATED?
49
CAN YOU DO ANYTHING TO PREVENT OR TREAT THIS?
50
DO YOU GRIND OR GRIT YOUR TEETH?
Yes
No
51
DO YOU HAVE OR HAVE YOU HAD ANY OF THE FOLLOWING?* This field is required.
SINUS PROBLEMS
HEARING CHANGES
STRESSFUL JOB
SENSITIVE TEETH
RINGING IN EARS
MARITAL PROBLEMS
PERIODONTAL DISEASE
DIZZINESS
TROUBLE SLEEPING
HEADACHES
SHOULDER PAIN
ULCERS
MIGRAINES
ARTHRITIS
NERVOUS STOMACH
NECK ACHE
SKIN DISEASES
ALLERGIES
EAR ACHE
DEPRESSION
OTHERS
52
LIST OTHER MEDICAL PROBLEMS
53
THE PAIN IS HAVING THIS EFFECT ON MY LIFE.* This field is required.
1
2
3
4
5
6
7
8
9
10
NO EFFECT
CANNOT FUNCTION AT ALL
54
Tags
Todo
In Progress
Done
Should be Empty: