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TMD / TMJ QUESTIONAIRE

For New Patients with TMJ/TMD Pain:

If you are going to be a new patient of ours, you may like to save yourself some time by filling out the following form. We have given you the choice of filling out an electronic form and a printable form. Click here for the printable form and when the page fully loads, select the print option from your browser's menu. When the form has been printed, please fill it out to the best of your knowledge and bring it into the office.

Our electronic form can be found below. Simply fill out the empty fields and select the appropriate options for your answers.

There are two parts to this form. The first part is for describing your beginning symptoms and the second section is for describing your present symptoms.

Please Fill Out This Form ONLY If You Have Made
An Appointment To Be a New Patient.

Please start by telling us your name and e-mail address:

Name: (required)

E-Mail: (required)


Please Describe The Pain In The Beginning:

1.) When did your TMJ/TMD problem start?

2.) Do you know what caused your problem?

3.) What were you doing when the problem started?

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

8.) 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...

Pain that came 1st:
Pain that came 2nd:
Pain that came 3rd:
Pain that came 4th:

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:

6.) Where is your problem now?

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?

9.) Which symptoms bother you the second most?

10.) Recently, the pain has been...

Slight 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?

Always present There are periods of no pain

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?

17.) Feel free to add any other comments in the box below:

 

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