Temporomandibular and Facial Pain Questionnaire
James D. Watson DDS, PA - Certified Orthodontic Specialist
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Rows
Yes
No
Does your jaw make noise so that it bothers you or other?
Does your jaw get stuck so that you can't open it freely?
Does it hurt when you chew or open wide to take a big bite?
Do you have ear aches or pain in the front of your ears?
Do you have pain in your face, cheeks, jaws, throat, or temples?
Are you unable to open your mouth as far as you want to?
Do you suffer from frequent headaches?
Are you aware that you grind your teeth at night?
Do you have a habit of clamping or "setting" your teeth?
Do you have any jaw symptoms or headaches upon waking in the morning?
Do you have to chew only on one side of your mouth?
Have you had a blow to the jaw?
Are you a habitual gum-chewer, pipe-smoker, or nail-biter?
Do you take any medications or pills for pain or discomfort (pain relievers, muscle relaxants, anti-depression pills, etc.)?
Do you have any pain or discomfort that affects your appetite?
Do you have any pain that causes you to be frustrated or depressed?
Do you suffer from arthritis of pain in other joints?
Do you suffer from a nervous stomach or ulcers?
Do you suffer from constipation or colitis?
Do you suffer from back or neck pain?
Have you ever had whiplash?
Do you suffer from skin problems?
Do you have any allergies?
Are you double-jointed anywhere?
Do you have any pain or discomfort that interferes with your daily routine or other activities?
Yes
No
If Yes, please describe:
Have you received treatment for jaw problems in the past?
Yes
No
Print Patient's Name
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Patient Signature
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Date
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Month
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Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Parent/Guardian Signature
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Date
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Month
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Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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