Form: TMJ Patient Information

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

1. Describe your problem

2. Do you have a clicking, popping or grating noise in your
Right Jaw JointYesNo

Left Jaw JointYesNo

3. When did you first notice the noise?

Right

Left

4. Has the noise recently become more pronounced?YesNo

When?

5. Do you have pain in or around the right joint?YesNo

Do you have pain in or around the left joint?YesNo

6. When did you first notice the pain?

Right

Left

7. Is the pain worse:
Mornings Evenings
At Meals No Specific Time

8. Has the pain recently become more pronounced?YesNo

When?

9. Is the pain:
Dull, achy Continuous Sharp, Stabbing
Intermittent Throbbing

If other, please describe:

10. Does the pain sometimes feel like it’s in your ear?YesNo

11. Do you think this problem has affected your hearing?YesNo

12. Do you hear a ringing noise (tinnitus)?YesNo

Constant Intermittent

13. Do you have vertigo (periods of dizziness)?YesNo

14. Does your jaw problem interfere with your normal activities?YesNo

15. Do you have any idea what triggered the problem, what caused it, or what makes the problem continue?YesNo

Explain

16. Do you have frequent headaches or neckaches?YesNo

What Area(s)?

How Frequent?

17. Have you ever had a severe blow or trauma to the head, neck, or jaw?YesNo

Which area?

Explain:

18. Do you have difficulty chewing?YesNo
Because of Pain in Joint Limited Opening Pain in Teeth
Missing Teeth Clicking
Other:

19. Has your mouth ever locked open so you were unable to close it?YesNo

Explain:

20. Have you had problems opening your mouth wide?YesNo

Explain:

21. Do you feel as if your teeth don’t have a “home base” to close to, or that your bite is changing?YesNo

22. Have you ever been told that you grind your teeth during sleep?YesNo

23. Please indicate the time sequence in which you became aware of the following problems list.YesNo

Number only those problems that apply to you.
Pain:

Noise:

Limited opening:

Locking:

Other:

24. Which aspects of your problem concern you the most?

25. Are you aware of clenching your teeth?YesNo

26. Do you grind your teeth?YesNo

27. Has there been a recent change in your lifestyle such as a change in marital status, childbirth,
change of employment, death in the immediate family or other stressful events?
YesNo

Explain:

28. Do you have young children under your care?YesNo

29. Do you smoke a pipe?YesNo

Do you chew gum?YesNo

Do you bite your nails?YesNo

Do you have any other nervous habits?YesNo

30. Describe any habits at work or home which might place your body in a strained or awkward posture
(such as holding a phone with a shoulder or carrying equipment.

31. Do you think nervous tension seems to affect this problem?YesNo

Explain:

32. Have you had problems with other joints?YesNo

Explain:

33. Is there any history of similar problems in your family?YesNo

34. Have you had orthodontic treatment?YesNo

When?

Where?

35. Have you had recent dental treatment?YesNo

If yes, when?

Where?

36. Describe your past dental treatment in general.

37. Have you ever had x-rays taken of your jaw joints?YesNo

When?

Where?

38. List the names of all the health professionals you have seen for treatment of this problem, chronologically.

39. Discuss the relative success of your prior treatment(s).

40. List all medications you are (a) now taking, (b) have taken for this problem.

41. Please comment on your nutrition.

42. Do you use vitamins?YesNo

If yes, name and give dosage.

43. Do you smoke?YesNo

How much?

44. Comment on your sleep patterns: Such as – time you go to sleep, sleep positions, amount of sleep, etc.

45. Are you afraid your problem is serious?YesNo

46. Any ideas as to what should be done?

47. Your medical history:

a. Are you under current medical care?YesNo

If yes, for what?

b. Any major illness or operations?YesNo

What?

When?

c. Are you now taking any drugs or medications other than what you might have mentioned in question #40?YesNo

If yes, please note.

d. Do you have any adverse reactions to drugs?YesNo

If yes, please note.

e. Do you consider yourself in good health?YesNo

Please comment:

48. Please add to the above information if you wish.

Signature of Parent or Guardian: Sign your name below (using your mouse or finger)
[signature* tmjinfo-signature background:#FFFFFF]

Date:

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