Occlusal/Temporomandibular Joint Examination Patient Questionnaire

Chief Complaint/Main Concern?

When did your Jaw Symptoms or Discomfort start?

Month/Year

PLEASE CHECK YES OR NO TO THE FOLLOWING QUESTIONS:

Are you aware of clenching your teeth during the day? *

Yes

No

Have you ever had orthodontic treatment? *

Yes

No

Have you ever had periodontal disease (pyorrhea)? *

Yes

No

Have you ever been told that you grind your teeth during your sleep? *

Yes

No

Do you have any pain or soreness around your eyes, ears, or other parts of your face? *

Yes

No

Do you have missing back teeth? *

Yes

No

Do you ever have headaches/migraine? *

Yes

No

Do you frequently have neck aches or stiff neck muscles? *

Yes

No

Do your jaw muscles become tired frequently? *

Yes

No

Do you have difficulty in opening your mouth wide? *

Yes

No

Do you have difficulty in swallowing? *

Yes

No

Have you ever received a severe blow to the side of your head or jaw? *

Yes

No

Have you ever had pain in your jaw joint? *

Yes

No

Have you ever had problems with your ears, such as ringing or change of hearing? *

Yes

No

Do you ever hear grating sounds from your jaw joint? *

Yes

No

Do you ever hear clicking or popping sounds from your jaw joint? *

Yes

No

Are you presently in any pain from your jaw joint or muscles? *

Yes

No

Does pain or discomfort from your jaw joint interfere with your work or activities? *

Yes

No

Do you feel you need treatment for this problem? *

Yes

No

Do you have a problem with insomnia? *

Yes

No

Are you taking any tranquilizers, hypnotics, muscle relaxants, or anti-depressants? *

Yes

No

Do you smoke cigarettes, cigars, or a pipe? *

Yes

No

Do you have problems with eating or chewing? *

Yes

No

Has your jaw ever locked (can't open or can't close) or slipped out of place? *

Have you ever had an injury to your neck (whiplash)? *

Yes

No

Do you suffer from frequent neck pain? *

Yes

No

Does your neck ever make clicking, grating, or popping noises or movements? *

Yes

No

Does your head or neck ever get stuck momentarily in a position so you cannot move it? *

Yes

No

Is your neck pain worse in waking? *

Yes

No

Do you have pain or numbness in your arms, fingers, or hands? *

Yes

No

Do you have painful sensations or numbness in the head, neck, or shoulder? *

Yes

No

Is your pain disturbed by pain of the head and neck region? *

Yes

No

Are your daily activities or routine disturbed by pain of the head and neck region? *

Yes

No

Have you ever had a traumatic injury? *

Yes

No

Type of Injury

Injury to jaw

Injury to neck

Injury to head

Injury to spine

Hearing problems

Yes

No

Is present stress higher than usual? *

Yes

No

Overall feeling with discomfort today from 1 - 10 *

1 = no discomfort - 10 = highest discomfort

Are you wearing an appliance now? If yes, what type?