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2925 Premiere Parkway, Suite 185 Duluth GEORGIA US 30097
(678) 336-8720
TMJ QUESTIONNAIRE
First Name
*
:
Last Name
*
:
Date of Birth
*
:
Phone Number :
Email :
CHIEF COMPLAINT
What is the main problem that brings you here ?
*
Did this problem begin :
Suddenly
Gradually
How long have you been bothered by this problem ?
Years
Months
Weeks
Days
PAIN SYMPTOMS
Location ( please circle all locations that you are having pain. Circle
R
for right,
L
for left )
Joint
R
L
Ear
R
L
Upper teeth / jaw
R
L
Lower teeth / jaw
R
L
Eyes
R
L
Face
R
L
Shoulders
R
L
Forehead
R
L
Neck
R
L
Headaches ( answer only if you have
regular
headaches ) :
How often ?
Location :
One Side
Both Sides
Time of Day :
Previous Diagnosis and Treatment :
Circle all the terms that describe your pain :
Sharp
Dull
Aching
Deep
Superficial
Burning
Pulsing
Spreading
Rate your pain today by placing a line on the following scale :
Is this pain :
Constant
Intermittent
Does the pain last for :
Minutes
Hours
Does the pain start :
Suddenly
Gradually
Does the pain stop :
Suddenly
Gradually
What time of the day is the pain most severe ?
What is the longest period of time you have gone with pain ?
What medication, if any, do you take for pain?
Does rest increase or decrease the pain?
Does positioning your head or jaw in a certain position relieve pain?
Yes
No
Briefly Describe :
Do any normal activities cause pain ?
Yes
No
Briefly Describe :
DYSFUNCTION
Can you open your mouth :
Normally
Partially
Very Limited
Has your jaw ever locked open or shut :
Yes
No
Do you have any of these sounds in your jaw joints :
Grating :
R
L
Clicking :
R
L
Snapping :
R
L
Popping :
R
L
If you have any of these problems, is it :
Frequently
Occasionally
Constantly
Have you noticed any change in your bite or ability to chew ?
Yes
No
OTHER COMPLAINTS & QUESTIONS
Do you have problems with your ears ?
Yes
No
If yes, are the problems :
Pain
Dizziness
Ringing
Other
Other :
Are your jaws clenched or teeth sore when you awaken from sleep?
Yes
No
Do you grind or clench your teeth?
Yes
No
Do you chew gum or ice?
Yes
No
Are your muscles ever tired?
Yes
No
Have you had orthodontic treatment ( braces )?
Yes
No
Have you ever had your bite adjusted by your dentist?
Yes
No
Do you play a musical instrument or sing?
Yes
No
Please list any other pertinent information you feel we should know:
Have you been treated previously for this problem?
By Whom
Telephone
Diagnosis & Treatment :
Next
TMJ QUESTIONNAIRE
PREVIEW
First Name :
Last Name :
Date of Birth :
Phone Number :
Email :
CHIEF COMPLAINT
What is the main problem that brings you here ?
Did this problem begin :
Suddenly
Gradually
How long have you been bothered by this problem ?
Years
Months
Weeks
Days
PAIN SYMPTOMS
Location ( please circle all locations that you are having pain. Circle
R
for right,
L
for left )
Joint
R
L
Ear
R
L
Upper teeth / jaw
R
L
Lower teeth / jaw
R
L
Eyes
R
L
Face
R
L
Shoulders
R
L
Forehead
R
L
Neck
R
L
Headaches ( answer only if you have
regular
headaches ) :
How often ?
Location :
One Side
Both Sides
Time of Day :
Previous Diagnosis and Treatment :
Circle all the terms that describe your pain :
Sharp
Dull
Aching
Deep
Superficial
Burning
Pulsing
Spreading
Rate your pain today by placing a line on the following scale :
Is this pain :
Constant
Intermittent
Does the pain last for :
Minutes
Hours
Does the pain start :
Suddenly
Gradually
Does the pain stop :
Suddenly
Gradually
What time of the day is the pain most severe ?
What is the longest period of time you have gone with pain ?
What medication, if any, do you take for pain?
Does rest increase or decrease the pain?
Does positioning your head or jaw in a certain position relieve pain?
Yes
No
Briefly describe :
Do any normal activities cause pain ?
Yes
No
Briefly describe :
DYSFUNCTION
Can you open your mouth :
Normally
Partially
Very Limited
Has your jaw ever locked open or shut :
Yes
No
Do you have any of these sounds in your jaw joints :
Grating :
R
L
Clicking :
R
L
Snapping :
R
L
Popping :
R
L
If you have any of these problems, is it :
Frequently
Occasionally
Constantly
Have you noticed any change in your bite or ability to chew ?
Yes
No
OTHER COMPLAINTS & QUESTIONS
Do you have problems with your ears ?
Yes
No
If yes, are the problems :
Pain
Dizziness
Ringing
Other
Other :
Are your jaws clenched or teeth sore when you awaken from sleep?
Do you grind or clench your teeth?
Do you chew gum or ice?
Are your muscles ever tired?
Have you had orthodontic treatment ( braces )?
Have you ever had your bite adjusted by your dentist?
Do you play a musical instrument or sing?
Please list any other pertinent information you feel we should know:
Have you been treated previously for this problem?
By Whom
Telephone
Diagnosis & Treatment :
Previous
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