TMJ/FACIAL PAIN OUESTIONNAIRE
Date: Click here to enter a date.
Patient Name: Click here to enter text.
Date of Birth: Click here to enter a date.
Referring Doctor: Click here to enter text.
Describe your problem: Click here to enter text.
What other Doctors or Healthcare Providers have you seen regarding this problem? Click here to enter text.
Help us locate and visualize your pain:
Quantify your pain on a scale of 0 to 10 (0 = no pain and 10 = worst pain)
Most of the time it is a Choose an item.
At its worst, it is a Choose an item.
At its least, it is a Choose an item.
(1) How long has this pain been present? Click here to enter text.
(2) Is the pain constant or intermittent (meaning “off and on”?) Choose an item.
(3) When is the pain worse? (select one) Choose an item.
(4) Does it hurt to move your jaw? (check one) ☐ Yes ☐ No
(5) Does anything you do make the pain worse? If so, what?
Click here to enter text.
THE PAIN / ACHING IS HAVING THIS EFFECT ON MY LIFE (Check one)
☐ SLIGHT: No effect or slight. Can work/play but am aware of the pain.
☐ MODERATE: Some days I am unable to function.
☐ SEVERE: Most days I am unable to function.
☐ DEBILITATING: I do not function at all.
On the images below, circle the area that hurts. On the menu above, select INSERT  Shapes  pick a circle  outline
the affected area below on the photos  FORMAT  Shape fill  select no fill.
(R)
(L)
HOW DOES THIS PAIN INTERFERE WITH YOUR NORMAL DIET? (Check one )
☐ I can eat a normal diet without pain
☐ I can eat a normal diet with minimal pain
☐ I can eat a normal diet but sometimes I eat soft or non-chewy foods and have a fair amount of pain
☐ I can eat a soft diet only. My pain interferes with eating
☐ I cannot eat a normal diet without pain. I am mostly on liquids
(6) Was there any event or injury which you believe may have caused this problem / pain? ☐ Yes
(7) Does the problem / pain limit your function? ☐ Yes
☐ No
☐ No If so, how?
Click here to enter text.
(8) Does your pain interfere with: (Check all that apply.)
☐CHEWING
☐ SPEAKING
☐ SLEEP
☐ LIFE IN GENERAL?
(9) Does your joint make noise?
☐ CLICK
☐ GRIND
☐ POPPING
(10) Does or has your jaw ever locked: ☐ OPEN
☐ CLOSED
☐ BOTH
(11) Do you do anything that initiates your pain / problem(s)? (Check all that apply.)
☐ GRIT OR GRIND YOUR TEETH ☐ NAIL BITING ☐ CHEW GUM ☐ CLENCHING
WHAT TYPE OF TREATMENT HAVE YOU HAD FOR THIS PAIN / PROBLEM?
Medicines: Click here to enter text.
Counseling: Click here to enter text.
Occlusal Adjustments: Click here to enter text.
Splint: Click here to enter text. How Many? Click here to enter text.
Orthodontics: Click here to enter text.
Physical Therapy: Click here to enter text.
Other: Click here to enter text.
DO YOU HAVE ANY OF THE FOLLOWING?
YES
NO
Sinus problems
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Allergies
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Periodontal Disease
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Sensitive Teeth
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Nervous Stomach
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Ulcers
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Dizziness
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Anxiety
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Depression
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Home / Job Stress
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Describe Allergies: Click here to enter text.
Skin Disease
Headaches
Migraines
Shoulder Pain
Neck Ache
Rheumatoid Arthritis
Hearing Changes
Ear Ache
Ringing in Ears
YES
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NO
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