Temporomandibular Disorder Questionnaire

* Denotes Required

Patient Name* :
Your Email*:
Date:
1. Do you have grating, clicking or popping sound in either or both jaws when you chew? YESNO
2. Do you have sensations or stiffness, pressure or blockage, ringing, hissing or buzzing in your ears? YESNO
3. Do you ever feel dizzy or faint? YESNO
4. Is your jaw painful or locked when you wake up in the morning? YESNO
5. Do you consider yourself chronically fatigued? YESNO
6. Are you ever nauseated for no apparent reason? YESNO
7. Do your fingers sometimes go numb? YESNO

8. Check any area where you have pain or soreness:

Jaw JointsUpper jaw or teethBack of headForeheadLower jaw or teethChewing musclesTemplesSide of neckBehind the eyesTongueOther

9. Is it hard to move your jaw side-to-side, forward or backward? YESNO
10. Do you have difficulty chewing? YESNO
11. Do you have back teeth missing? YESNO
12. Have you had extensive dental crowns and bridgework? YESNO
13. Do you clench your teeth during the day? YESNO
14. Do you grind your teeth at night? (Ask someone else) YESNO
15. Do you ever have a headache when you wake up? YESNO
16. Have you had whiplash injury? YESNO
17. Have you worn a cervical collar or had neck traction? YESNO
18. Have you ever had a blow to chin, face or head? YESNO
19. Have you reached the point at which drugs no longer relieve your symptoms? YESNO
20. Does chewing gum start your symptoms? YESNO
21. Does your jaw deviate to the left or right when you open wide? YESNO
22. When your mouth is wide open, can you insert three fingers into your mouth vertically? YESNO

23. Please write a brief narrative of your past medical and dental history (including injuries) pertaining to the jaw joint:

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