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TMJ-TMD-MSD Questionnaire

TMJ=Temporo-Mandibular Joint (Jaw joint) problem; TM Disorder & Muscle Skeletal Disorder=bad bite that may or may not include jaw joint problem.

If you know you have a TMJ-TMD-MSD problem, please print, fill out and bring this form to your first consultation.

Name

1. Describe your problem

2. What do you think caused this problem?

3. Describe what you expect from treatment

GENERAL HISTORY:

1. Are you presently under the care of a physician?

Yes

No

Have you been in the past year?

Yes

No

Condition treated

Physician's name

Treatment received

Name of medication(s) you are currently taking

2. How would you describe your overall physical health? (0=Poor, 10=Excellent)

0

1

2

3

4

5

6

7

8

9

10

3. How would you describe your dental health? (0=Poor, 10=Excellent)

0

1

2

3

4

5

6

7

8

9

10

Dentist's name

Date of last appointment

4. Have you had any major dental treatment in the last two years?

Yes

No

If yes, please indicate which one(s):

Orthodontics

Periodontics

Oral Surgery

Restorative (filling, crown, bridge, partial or full denture, implant)

Date(s) of third molar (wisdom tooth) extraction(s)

FACIAL INJURY/TRAUMA HISTORY

Is there any childhood history of falls, accidents or injuries to the face or head?

Yes

No

Describe childhood injuries

Is there any recent history of trauma to the head or face?

Yes

No

If yes, please indicate type(s):

Auto accident

Sports injury

Facial impact

Describe recent trauma

Is there any activity, which holds the head or jaw in an imbalanced position?

Yes

No

If yes, please indicate which:

Phone

Swimming

Instrument

Describe imbalanced position activities

TMJ-TMD-MSD TREATMENT HISTORY

1. Have you ever been examined for a TMJ-TMD-MSD problem before?

Yes

No

If yes, by whom?

When?

2. What was the nature of the problem?

Pain

Noise

Limitation of movement

3. What was the duration of the problem? (Months)

Problem duration (Years)

Is this a new problem?

Yes

No

4. Is the problem Getting better, Getting worse, or Staying the same?

Getting better

Getting worse

Staying the same

5. Have you ever had physical therapy for TMJ-TMD-MSD?

Yes

No

If yes, by whom?

6. Have you ever received treatment for jaw problems?

Yes

No

If yes, by whom?

What type of treatment did you receive?

Bite Splint

Medication

Physical therapy

Occlusal Adjustment

Orthodontics

Counseling

Surgery

Other

Other treatment description

CURRENT PAIN LEVEL/MEDICATIONS/APPLIANCES

1. Degree of current TMJ-TMD-MSD pain (0=None, 10=Severe)

0

1

2

3

4

5

6

7

8

9

10

2. Frequency of TMJ-TMD-MSD pain

Daily

Weekly

Monthly

Semi-Annually

7. Is there a pattern related to pain occurrence?

Yes

No

When does the pain typically occur?

Upon waking

Morning

Afternoon

Evening

After Eating

3. Are you taking medication for the TMJ-TMD-MSD problem?

Yes

No

If yes, what type?

How long taking medication?

Who prescribed the medication?

4. Are the medications that you take effective?

Yes

No

Conditional

5. Are you aware of anything that makes your pain worse?

Yes

No

If yes, describe what makes pain worse

6. Does your jaw joint make noise?

RIGHT - Click

RIGHT - Pop

RIGHT - Grind

LEFT - Click

LEFT - Pop

LEFT - Grind

Other jaw joint noise

7. Does your jaw lock open?

Yes

No

When did jaw lock open first occur?

How often does jaw lock open?

8. Has your jaw ever locked closed or partly closed?

Yes

No

When did jaw lock closed first occur?

How often does jaw lock closed?

9. Have any dental appliances been prescribed?

Yes

No

If yes, by whom?

When were appliances prescribed?

Describe dental appliances

10. Are these appliances effective?

Yes

No

11. Is there any additional information that can help us in this area?

CURRENT STRESS FACTORS

Please indicate any current stress factors:

Death of spouse

Major Illness or Injury

Business adjustment

Financial problems

Fired from work

Death of a family member

New person joins family

Marital separation

Major health change in family

Divorce

Pending marriage

Pregnancy

Marital reconciliation

Taking on debt

Career change

Other stress factors - Describe

HABIT HISTORY

1. Do you grind or clench your teeth together under stress?

Yes

No

Don't know

2. Do you grind or clench your teeth at night?

Yes

No

Don't know

3. Do you sleep with an unusual head position?

Yes

No

Don't know

4. Are you aware of any habits or activities that may aggravate this condition?

Yes

No

Don't know

Describe aggravating habits

SYMPTOMS - check or circle what applies

HEAD, FACE PAIN

Head and face pain symptoms:

Head R

Head L

Face R

Face L

Forehead R

Forehead L

Temple R

Temple L

Migraine headaches

Cluster headaches

Sinus headaches under the eyes

Headache back of head

Painful to touch hair scalp R

Painful to touch hair scalp L

EYE, EYE SOCKET

Eye and eye socket symptoms:

Pain above eye

Pain below eye

Pain behind eye

Bloodshot R

Bloodshot L

Bulging R

Bulging L

Blurred vision R

Blurred vision L

Pressure behind eye R

Pressure behind eye L

Light sensitivity

Watering eye R

Watering eye L

Drooping eyelid R

Drooping eyelid L

MOUTH, FACE, CHEEK, CHIN

Mouth, face, cheek, and chin symptoms:

Discomfort

Limited opening

Inability to open smoothly

TEETH, GUMS

Teeth and gum symptoms:

Clenching

Grinding Day

Grinding Night

Back teeth loose sore R

Back teeth loose sore L

Tooth pain R

Tooth pain L

Gums sore bleeding

JAW, JAW JOINT

Jaw and jaw joint symptoms:

Jaw joint clicking popping R

Jaw joint clicking popping L

Jaw joint grating sound R

Jaw joint grating sound L

Jaw locking opened

Jaw locking closed

Uncontrollable movement jaw

Uncontrollable movement tongue

EARS

Ear symptoms:

Hissing R

Hissing L

Buzzing R

Buzzing L

Ringing R

Ringing L

Roaring R

Roaring L

Pain without infection R

Pain without infection L

Clogged R

Clogged L

Stuffy R

Stuffy L

Itchy R

Itchy L

Balance problem

Vertigo

Dizziness

Diminished hearing R

Diminished hearing L

NECK, SHOULDER, BACK

Neck, shoulder, and back symptoms:

Reduced mobility neck shoulder

Neck stiff pain

Shoulder stiff pain R

Shoulder stiff pain L

Neck muscles tired sore

Back pain upper

Back pain lower

Arm tingling R

Arm tingling L

Arm numb R

Arm numb L

Arm pain R

Arm pain L

Finger tingling R

Finger tingling L

Finger numb R

Finger numb L

Finger pain R

Finger pain L

THROAT

Throat symptoms:

Swallowing difficulties

Tightness

Sore

Voice fluctuation

Laryngitis

Frequent coughing clearing

Feels like foreign object in throat

Tongue pain

Excess salivation

Pain in palate

OTHER SYMPTOMS - Describe

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Thank You!

We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.

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