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?

Rows	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?

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:

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

Do you have:

Rows	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:

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

Do your jaw joints make noise?

If yes, which side and please describe the noise?

Have you ever been unable to open your mouth wide?

If yes, please explain:

Do you sleep well at night?

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?

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

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:

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

Are you aware of oral habits such as:

Rows	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?

Does your pain occur when you eat?

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

Do you have unexplainable scalp tenderness?

Are you experiencing unexplainable/unintentional weight loss?

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

Do you have visual symptoms/visual loss?

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