TMJ Questionnaire Patient Name First Last Patient Email Patient Age Patient Birth Date (mm/dd/yyyy) MM slash DD slash YYYY Patient Home PhonePatient Work PhonePatient Cell PhonePatient Sex Male Female Patient Marital Status Single Married Divorced, Separated Widow, Widower Patient Occupation CHIEF 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) MM slash DD slash YYYY Did it begin suddenly or gradually? Suddenly Gradually Duration of problem It hurts constantly It hurts occassionally When does it hurt? (Details helpful)Has the problem progressed? Is it... Better Worse Staying the same List the names of all health professionals you have seen for treatment, chronologically.Date of visit (mm/dd/yyyy) MM slash DD slash YYYY Doctor's name Dr.'s Address Dr.'s Phone #Date of visit (mm/dd/yyyy) MM slash DD slash YYYY Doctor's name Dr.'s Address Dr.'s Phone #Date of visit (mm/dd/yyyy) MM slash DD slash YYYY Doctor's name Dr.'s Address Dr.'s Phone #Date of visit (mm/dd/yyyy) MM slash DD slash YYYY Doctor's name Dr.'s Address Dr.'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? Yes No Have you ever been treated for a “bad bite”? Yes No Have you ever had orthodontic treatment? Yes No Have you ever had treatment for jaw joint problems or facial muscle spasms? Yes No Do you have extensive dental crowns or bridges? Yes No Do you have missing back teeth? Yes No Do you wear a removable partial denture? Yes No Do you ever awaken with an awareness of your teeth or jaws? Yes No Are you aware of clenching your teeth during the day? Yes No Have you ever been told that you grind your teeth in your sleep? Yes No Do your teeth hurt from biting? Yes No Do you have pain or soreness around your eyes, ears, or other parts of your body? (Eg.back and shoulders) Yes No Do you have difficulty hearing? Yes No Do you have “tension” headaches? Yes No Do you have occasional headaches? Yes No Do you ever have migraine headaches? Yes No Do you frequently have stiff neck muscles or neck aches? Yes No Do your jaw muscles become tired frequently? Yes No Do you have difficulty opening your mouth widely? Yes No Have you ever had any form of arthritis? Yes No Does any family member or relative have arthritis or gout? Yes No Have you ever received a severe blow to the side of the head or to the jaw? Yes No Have you ever had pain in your jaw joint? Yes No Have you had any hearing loss or ringing of the ears? Yes No Do you ever hear grating sounds from your jaw joints? Yes No Do you ever hear clicking or popping sounds from your jaw joints? Yes No Do you feel that your bite is closed? Yes No Are you presently in any pain from your jaw joints or muscles? Yes No Does your pain or discomfort from your jaw joint interfere with your work or other activities? Yes No Are there times when you notice this problem or pain is less or gone completely? Yes No Do you feel depressed? Yes No Have you ever seen a Psychologist or Psychiatrist for treatment? Yes No Do you have a problem with insomnia? Yes No Are you under a great deal of stress? (Eg. job, family, social, school, etc.) Yes No Do you take more than one alcoholic drink per day? Yes No Do you smoke cigarettes, cigars, or a pipe? Yes No Do you bite your nails, tongue, or lips? Yes No Do you chew gum? Yes No Do you sleep on your stomach? Yes No Do you feel that your pain is related to stress? Yes No Do you have any idea what has caused your problem? Yes No Δ
