mcbride@rpmdentistry.com
562.421.3747
Form: TMJ Patient Information

Form: TMJ Patient Information



Please answer all questions to the best of your ability - use additional paper if necessary.



YesNo

YesNo

YesNo

YesNo

YesNo


Mornings Evenings
At Meals No Specific Time

YesNo


Dull, achy Continuous Sharp, Stabbing
Intermittent Throbbing

If other, please describe:


YesNo

YesNo

YesNo

Constant Intermittent

YesNo

YesNo

YesNo


YesNo

YesNo

YesNo
Because of Pain in Joint Limited Opening Pain in Teeth
Missing Teeth Clicking
Other:

YesNo


YesNo


YesNo

YesNo

YesNo



YesNo

YesNo


YesNo


YesNo

YesNo

YesNo

YesNo

YesNo


YesNo


YesNo


YesNo

YesNo

YesNo


YesNo



YesNo



YesNo


YesNo

YesNo

YesNo

YesNo



YesNo



YesNo





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