TMJ Questionnaire

Name*

First NameLast Name

Draw on the image the areas where you are experiencing pain:

Please describe the areas of pain:*

Around when did your pain/problem begin?*

Date

What do you believe triggered the pain/problem?*

What makes the pain/problem feel worse?*

What makes the pain/problem feel better?*

What treatment(s), if any, have you received?*

When is your pain the worst?*

What does the pain keep you from doing?*

Would you use the following words to describe your pain?*

	Yes	No
Ache
Pressure
Dull
Sharp
Throbbing
Burning
Wake you up at night?
Increases while lying down?
Increases while bending forward?
Increases when drinking hot/cold beverages?

How would you rate your present pain level? (1: No Pain, 10: Worst Pain Imaginable)*

How would you rate the average pain level over the past 6 months? (1: No Pain, 10: Worst Pain Imaginable)*

Is your pain always present?*

YesNo

If no, how often do you experience the pain?*

Please describe any symptoms other than pain that you associate with your problem:*

Have you had:*

	Yes	No
Head/Neck Surgery
Whiplash/Trauma to Head/Neck
Shingles on Head/Neck

Do you have:*

	Yes	No
A Fever
Nasal Congestion/Stuffiness
Movement Difficulties of Facial Muscles/Eyes/Mouth/Tongue
Numbness/Tingling
Teeth Problems
Swelling Over Jaw Joints/Mouth/Throat
Certain Spot that Triggers Pain
Recurrent Swelling/Tenderness of Joints Other than Jaw Joint
Morning Stiffness in Body, Other than Jaw Joint
Muscle Tenderness in Body (Other than Head/Neck) for more than 50% of the Time

Is your pain/problem worse:*

	Yes	No
When Swallowing/Turning Your Head
After Reading/Straining Eyes

Do your jaw joints make noise?*

YesNo

If yes, which side and please describe the noise?*

Have you ever been unable to open your mouth wide?*

YesNo

If yes, please explain:*

Do you sleep well at night?*

YesNo

How often are you tense, aggravated or frustrated during a typical day?*

How often do you feel depressed during a typical day?*

Do you have thoughts of hurting yourself or committing suicide?*

YesNo

Do you play a musical instrument and/or sing more than 5 hours in a typical week?*

YesNo

Around what percent of the day your teeth seem to be touching or coming together with the bottom teeth against the top teeth?*

Are you aware of clenching or grinding your teeth:*

	Yes	No
When Sleeping
While Driving
When Using a Computer
Other Times
Not Aware

Are you aware of oral habits such as:*

	Yes	No
Chewing Your Cheeks
Chewing Objects
Biting Your Nails/Cuticles
Thrusting Your Jaw
Other Habits
Not Aware

What treatment do you think is needed for your problem?*

Is there anything else you think we should know about your problem?*

Are you 50 years of age or older?*

YesNo

Does your pain occur when you eat?*

YesNo

Are you pain-free when you open your mouth wide?*

YesNo

Do you have unexplainable scalp tenderness?*

YesNo

Are you experiencing unexplainable/unintentional weight loss?*

YesNo

Do you have significant morning stiffness lasting more than 30 minutes?*

YesNo

Do you have visual symptoms/visual loss?*

YesNo

To the best of my knowledge, the information given in this form is correct and I give permission for a written report to be sent to my referring and treating doctors and dentists.

Patient Name*

First NameLast Name

Signature*

Date*

Date