Slowly
All of a sudden Describe the pain in the beginning:
1.) When did your TMJ/TMD problem start?
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2.) Do you know what caused your problem?
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3.) What were you doing when the problem started?
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4.) Did the problem start slowly or all of a sudden?
Slowly
All of a sudden
5.) When did you start noticing your problem?
During sleep
In the morning
While chewing
During the
day During
the evening
6.) In the beginning was the pain was ...
Mild
Moderate
Severe
7 .) In the beginning, the pain would last...
Minutes
Hours
Days
Weeks
For a prolonged amount
of time
9.) In the beginning, how did the pain feel?
Dull/Aching
Pulsing
Burning Sharp
stabs Electrical
Describe the pain now:
1.) Please indicate which pains came 1st, 2nd, 3rd, and 4th...
Face ___
Front of head ___
Back of head ___
Neck ___
2.) How does your pain feel now?
Dull/Aching
Pulsing
Burning Sharp
stabs Electrical
3.) Is the intensity of the pain getting...
Worse
Getting better
Same
4.) How long does your pain last for now?
Minutes
Hours
Days
Weeks
For a prolonged amount
of time
5.) Does your pain feel like it is changing over time? Please describe it:
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6.) Where is your problem now?
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7.) Please select the options that best describe the conditions of the following areas of your body:
a.) The area near the immediate front of your ears:
Pain Clicking
Popping
Paper crackling
Locked close
Locked open
b.) Your jaw in the region of the cheek & side of the face:
In pain No pain
c.) Your ear(s):
Pain Stuffiness
Ringing
Loss of hearing
d.) In what area of your head is the pain, mostly?
Temple(s) Forehead
Front of head
Top of head
Back of head
e.) Your eyes:
In pain Blurry
vision
f.) Your neck and shoulders:
Pain Stiffness
Noise
Weak
g.) Your arms and fingers:
In pain Burning
Cold
Numb Tingling
8.) Which symptoms bother you the most?
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9.) Which symptoms bother you the second most?
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10.) Recently, the pain has been...
Mild
Moderate
Severe
11.) Recently, the pain has lasted for...
Minutes
Hours
Days
Weeks
For a prolonged amount
of time
12.) Is the pain easy to localize or diffused and hard to localize?
Easy to localize
Diffused and hard
to localize
13.) Does the pain feel...
Dull/Aching
Pulsing
Burning Sharp
stabs Electrical
14.) Is the pain always present? Or are there periods of no pain?
Dull/Aching
Pulsing
15.) Please indicate which of the following functions are compromised by indicating it by per cent (%):
Daily activity ___
Work ___
Eating ___
Talking ___
Sleep ___
Family Relationships ___
Friendships ___
16.) What medications do you take now?
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17.) Feel free to add any other comments in the box below:
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