TMJ Problem Questionnaire Full Name Age Date Referred By Which of the following do you have? Which of the following do you have? Headaches Neck Pain Jaw Pain Ear Pain Facial Pain Other Which side hurts? Which side hurts? Right Left Both How long have you had this pain? Is the pain constant? Is the pain constant? Yes No Is the pain? Is the pain? Yes No Stabbing Other Is the pain worse Is the pain worse Morning Afternoon Evening Night Have you ever injured or sustained an form of trauma or whiplash to your Have you ever injured or sustained an form of trauma or whiplash to your Jaw Head Neck What makes the pain better? What makes the pain worse? Does is hurt to chew? Does is hurt to chew? Yes No Does is hurt to open wide? Does is hurt to open wide? Yes No Which side of your jaw makes a popping noise? Which side of your jaw makes a popping noise? L R Which side of your jaw makes a clicking noise? Which side of your jaw makes a clicking noise? L R Which side of your jaw makes other noises? Which side of your jaw makes other noises? L R What noises? When did you first notice joint noises? Has your jaw ever locked? Has your jaw ever locked? Yes No Did it lock open or closed? Did it lock open or closed? Open Closed When did this first happen? When did this last happen? Which side? Which side? L R Has your jaw ever slipped out of place Has your jaw ever slipped out of place Yes No Have you noticed a change in your bite? Have you noticed a change in your bite? Yes No Did you notice a change at your front teeth? Did you notice a change at your front teeth? Yes No Did you notice a change at your back teeth? Did you notice a change at your back teeth? Yes No Has your profile changed? Has your profile changed? Yes No Have you noticed any crookedness or asymmetry in your jaw? Have you noticed any crookedness or asymmetry in your jaw? Yes No When did you notice the asymmetry? When did you notice the asymmetry? Yes No When did you notice the asymmetry? Do you clench your teeth? Do you clench your teeth? Yes No Are your teeth sore or sensitive? Are your teeth sore or sensitive? Yes No Do you have loose teeth? Do you have loose teeth? Yes No Do you have thermal Sensitivity (Hot / Cold)? Do you have thermal Sensitivity (Hot / Cold)? Yes No Do you clench your teeth? Do you clench your teeth? Yes No Do you grind your teeth? Do you grind your teeth? Yes No Do you do this during the day or night? Do you do this during the day or night? Yes No Do you have problems with your ears? When did you start clenching or grinding? Dizziness Dizziness Yes No Do you have postural problems Do you have postural problems Yes No Ringing Ringing Yes No Hearing Hearing Yes No Other? Other? Yes No Is it difficult to swallow? Is it difficult to swallow? Yes No Do you have cervical pain Do you have cervical pain Yes No Do you have Paresthesia of Fingertips (tingling) Do you have Paresthesia of Fingertips (tingling) Yes No Do you have Trigeminal Neuralgia Do you have Trigeminal Neuralgia Yes No Have you had any prior treatment for TMJ? Have you had any prior treatment for TMJ? Yes No Do you have Bells Palsy Do you have Bells Palsy Yes No Do you have Nervousness/Insomnia Do you have Nervousness/Insomnia Yes No Nightguard? Nightguard? Yes No When? Did it help? Did it help? Yes No Bite Adjustment? Bite Adjustment? Yes No When? Did it help? Did it help? Yes No When? Did it help? Did it help? Yes No Other? Describe the problems in your own words as you understand them: Reports may be sent to my: Reports may be sent to my: Medical Doctor Dentist Other I have completed the above to the best of my knowledge and I personally have filled in each blank in my own writing. I consent to the use of my x-rays, records and photos for scientific publication or teaching providing my name remains anonymous. I have completed the above to the best of my knowledge and I personally have filled in each blank in my own writing. I consent to the use of my x-rays, records and photos for scientific publication or teaching providing my name remains anonymous. Click to Confirm 2 + 7 = Submit CONTACT us Click for an Appointment Email us Today DrMartyFrankel@rogers.com Call us Today (416) 770-8526 Our Location 3080 Yonge Street, Suite 3030, Toronto, Ontario, M4N 3N1