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