TMJ Examination Form
Please complete all sections to assist with your temporomandibular joint (TMJ) assessment.
Patient Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Contact Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Chief Complaint (describe your main TMJ-related concern)
*
Duration of Symptoms
*
Please Select
Less than 1 week
1-4 weeks
1-6 months
More than 6 months
Location of Pain/Discomfort
*
Right TMJ
Left TMJ
Both Sides
Jaw Muscles
Neck
Other
Describe the nature of your pain
Sharp
Dull
Aching
Throbbing
Clicking/Pop sound
Locking
Other
Onset or triggers of symptoms
Do you experience any of the following?
Difficulty opening mouth
Jaw locking (open or closed)
Jaw deviation on opening
Ear pain or ringing
Headaches
Other
Medical and Dental History (including previous TMJ treatments, trauma, or relevant conditions)
TMJ Examination Findings
Rows
Right Side
Left Side
Tenderness on palpation
1
2
Clicking/crepitus on movement
3
4
Limitation of mouth opening
5
6
Jaw deviation on opening
7
8
Maximum mouth opening (mm)
Pain Intensity (0 = No pain, 10 = Worst pain)
*
No pain
0
1
2
3
4
5
6
7
8
9
Worst pain
10
0 is No pain, 10 is Worst pain
Additional Notes / Clinical Impression
Patient/Guardian Signature
Submit Examination
Submit Examination
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