TMJ Health Questionnaire
Name:
Sex:
M
F
Age:
Date
Jaw Joint Symptoms
Do you have pain in jaw joints(s)?
Y
N
R
L
Does your jaw feel tired when you chew?
Y
N
R
L
Does your jaw ache when you open wide?
Y
N
R
L
Do you feel or hear a “clicking”, “popping” or “cracking noise from either jaw joint?
Y
N
R
L
Do you avoid eating hard foods?
Y
N
Has your jaw ever locked so you were unable to open or close?
Y
N
Do you have difficulty opening wide or yawning?
Y
N
When are your symptoms worst?
What medication, if any, are you taking?
How often do you take medicine for pain relief?
a). never
b). daily
c). weekly
d). weekly to monthly
Other Pain Symptoms
Do you get tension headaches?
Y
N
Do you get migraine headaches?
Y
N
Do you get headaches in the temple areas?
Y
N
Do you get headaches in the back of the head?
Y
N
Do you have neck aches or stiff neck muscles?
Y
N
Have you had chronic shoulder, neck or or back pain? (Indicate which)
Y
N
Do you grind your teeth?
Y
N
Are your teeth sore upon awakening?
Y
N
Ear and Eye Symptoms
Do you have itchiness or stuffiness in either ear?
Y
N
R
L
Do you get pain in, around or behind either ear?
Y
N
R
L
Do you hear ringing, buzzing or hissing sounds in either ear?
Y
N
R
L
Do you hear grating noises in either ear?
Y
N
R
L
Breathing
Do you have allergies?
Y
N
Do you have sinus problems?
Y
N
R
L
Trauma or accidents
Have you ever had a severe blow to the head or jaw?
Y
N
Have you ever had a whiplash injury?
Y
N
Have you been involved in any serious accidents such as a car accident?
Y
N
Details
Dental History
Do you have a toothache at this time?
Y
N
If yes, indicate where (please circle):
Upper
Lower
Front
Back
Right
Left
Do you feel that your bite has changed?
Y
N
Have you had surgery on one or both jaw joints?
Y
N
If yes, indicate when and what was done:
Do you have problems with other joints in your body?
Y
N
If yes, which joints?