TMJ Questionnaire Patient Name First Last Patient Email Patient AgePatient Birth Date (mm/dd/yyyy) Date Format: MM slash DD slash YYYY Patient Home PhonePatient Work PhonePatient Cell PhonePatient SexMaleFemalePatient Marital Status Single Married Divorced, Separated Widow, Widower Patient OccupationCHIEF COMPLAINT: What is the nature of your pain or problem? (Headache, jaw pain, jaw clicking, ringing of ears, muscle pain, difficulty chewing, etc.) List all that applyDescribe your pain disorderWhen did you first notice that you had a problem? (Date of onset) Date Format: MM slash DD slash YYYY Did it begin suddenly or gradually?SuddenlyGraduallyDuration of problemIt hurts constantlyIt hurts occassionallyWhen does it hurt? (Details helpful)Has the problem progressed? Is it...BetterWorseStaying the sameList the names of all health professionals you have seen for treatment, chronologically.Date of visit (mm/dd/yyyy) Date Format: MM slash DD slash YYYY Doctor's nameDr.'s AddressDr.'s Phone #Date of visit (mm/dd/yyyy) Date Format: MM slash DD slash YYYY Doctor's nameDr.'s AddressDr.'s Phone #Date of visit (mm/dd/yyyy) Date Format: MM slash DD slash YYYY Doctor's nameDr.'s AddressDr.'s Phone #Date of visit (mm/dd/yyyy) Date Format: MM slash DD slash YYYY Doctor's nameDr.'s AddressDr.'s Phone #List ALL medications you are now taking, or have taken for this problem. Include the date of the medication and who prescribed it.If you have any x-rays of your TMJ, please bring them to the appointment.Do you wear or have you worn a splint, bite plate, or appliance?YesNoHave you ever been treated for a “bad bite”?YesNoHave you ever had orthodontic treatment?YesNoHave you ever had treatment for jaw joint problems or facial muscle spasms?YesNoDo you have extensive dental crowns or bridges?YesNoDo you have missing back teeth?YesNoDo you wear a removable partial denture?YesNoDo you ever awaken with an awareness of your teeth or jaws?YesNoAre you aware of clenching your teeth during the day?YesNoHave you ever been told that you grind your teeth in your sleep?YesNoDo your teeth hurt from biting?YesNoDo you have pain or soreness around your eyes, ears, or other parts of your body? (Eg.back and shoulders)YesNoDo you have difficulty hearing?YesNoDo you have “tension” headaches?YesNoDo you have occasional headaches?YesNoDo you ever have migraine headaches?YesNoDo you frequently have stiff neck muscles or neck aches?YesNoDo your jaw muscles become tired frequently?YesNoDo you have difficulty opening your mouth widely?YesNoHave you ever had any form of arthritis?YesNoDoes any family member or relative have arthritis or gout?YesNoHave you ever received a severe blow to the side of the head or to the jaw?YesNoHave you ever had pain in your jaw joint?YesNoHave you had any hearing loss or ringing of the ears?YesNoDo you ever hear grating sounds from your jaw joints?YesNoDo you ever hear clicking or popping sounds from your jaw joints?YesNoDo you feel that your bite is closed?YesNoAre you presently in any pain from your jaw joints or muscles?YesNoDoes your pain or discomfort from your jaw joint interfere with your work or other activities?YesNoAre there times when you notice this problem or pain is less or gone completely?YesNoDo you feel depressed?YesNoHave you ever seen a Psychologist or Psychiatrist for treatment?YesNoDo you have a problem with insomnia?YesNoAre you under a great deal of stress? (Eg. job, family, social, school, etc.)YesNoDo you take more than one alcoholic drink per day?YesNoDo you smoke cigarettes, cigars, or a pipe?YesNoDo you bite your nails, tongue, or lips?YesNoDo you chew gum?YesNoDo you sleep on your stomach?YesNoDo you feel that your pain is related to stress?YesNoDo you have any idea what has caused your problem?YesNo
