TMJ Problem

Questionnaire

Which of the following do you have?

Which side hurts?

Is the pain constant?

Is the pain?

Is the pain worse

Have you ever injured or sustained an form of trauma or whiplash to your

Does is hurt to chew?

Does is hurt to open wide?

Which side of your jaw makes a popping noise?

Which side of your jaw makes a clicking noise?

Which side of your jaw makes other noises?

Has your jaw ever locked?

Did it lock open or closed?

Which side?

Has your jaw ever slipped out of place

Have you noticed a change in your bite?

Did you notice a change at your front teeth?

Did you notice a change at your back teeth?

Has your profile changed?

Have you noticed any crookedness or asymmetry in your jaw?

When did you notice the asymmetry?

Do you clench your teeth?

Are your teeth sore or sensitive?

Do you have loose teeth?

Do you have thermal Sensitivity (Hot / Cold)?

Do you clench your teeth?

Do you grind your teeth?

Do you do this during the day or night?

Dizziness

Do you have postural problems

Ringing

Hearing

Other?

Is it difficult to swallow?

Do you have cervical pain

Do you have Paresthesia of Fingertips (tingling)

Do you have Trigeminal Neuralgia

Have you had any prior treatment for TMJ?

Do you have Bells Palsy

Do you have Nervousness/Insomnia

Nightguard?

Did it help?

Bite Adjustment?

Did it help?

Did it help?

Reports may be sent to my:

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.

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