TMJ Questionnaire

Please correct the errors described below.

Patient Information

  1. Please rank your complaints in order of severity with #1 being the most severe complaint, #2 the next, etc.
  2. Then rate your complaints for frequency, intensity, and duration

Add Complaint

List of Health Care Providers:

List the name, area of specialty, and address of all healthcare providers that are currently taking care of you. This should include, but is not limited to, primary care Physician, ENT, Neurologist, Rheumatologist, Dentist, Chiropractor, Physical Therapist, Acupuncturist, Nutritionist, Psychiatrist, Psychologist, Massage Therapist, etc.

Additional Healthcare Providers

Additional Factors

Prescription medications: List all prescription medications, dosage, when in the day you take it, and who prescribed it: (attach additional sheet if more space is needed)

List all health care providers that you have seen for your present condition. Include their area of specialty, treatment provided, effectiveness of treatment, and date of treatment: (effectiveness scale 0-3 where 0=not effective and 3=very effective)

Add new row


Ear Nose Throat

In recent months have the headaches:

Muscle Aches

Add additional Muscle Ache

Numbness or diminished sensation in:

Oral / Facial:

Nasopharyngeal (nose/throat):


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