TMJ Physical Therapy Evaluation
Please complete this form to assist with your TMJ assessment and treatment planning.
Patient Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
What is the main reason for your visit? (Chief Complaint)
*
When did your symptoms begin?
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Please rate your current jaw pain
*
1
2
3
4
5
6
7
8
9
10
Which of the following symptoms are you experiencing?
*
Jaw pain
Jaw clicking/popping
Locking of the jaw
Headaches
Ear pain or ringing
Difficulty chewing
Other
What makes your symptoms worse?
What helps relieve your symptoms?
Previous treatments or interventions for TMJ symptoms
Functional Limitations (Check all that apply)
Difficulty opening mouth
Difficulty closing mouth
Difficulty eating/chewing
Difficulty speaking
Other
Medical and Dental History (Relevant conditions, surgeries, or trauma)
TMJ Clinical Examination
Rows
Normal
Limited
Painful
Jaw opening
1
2
3
Jaw closing
4
5
6
Lateral jaw movement (side to side)
7
8
9
Protrusion (moving jaw forward)
10
11
12
Joint sounds (clicking/popping)
13
14
15
Palpation tenderness
16
17
18
Additional Notes / Therapist Observations
Signature (Patient or Guardian)
*
Submit Evaluation
Submit Evaluation
Should be Empty: