TMJ Questionnaire

Patient Information

Today's Date

Name

Age

Date of Birth

Address

City

State

Zip

Home Phone

Work Phone

Cell Phone

Email address

Employed By

Physician's Name

Address

Referred By

What are the reason for your visit today?

When did your symptoms start?

What do you believe is the cause of your pain or present condition?

How does your present condition affect your quality of Life? Have you had to change the way you do things or eliminate certain activities from your life?

Has anyone in your family had a similar condition to what you are experiencing now? If so, who?

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

Add Complaint

If complaint is not listed, please write it here

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

List all previously diagnosed medical conditions

List all traumatic injuries or accidents, and when they occurred from childhood until the present: (examples: car accident, work related accident, fall, fight, athletic endeavor)

List all surgeries, when they occurred, and who performed them

Do you, or have you ever used tobacco products?

Yes No

If yes, explain: (type, years of use, use per day)

Do you exercise regularly?

Yes No

If yes, Explain

What is your daily caffeine exposure? (coffee, tea, soda, energy drinks, etc.- cups, cans, bottles, etc./day)

On average, how many hours of sleep do you get per night?

Do you wake up in the middle of the night?

Yes No

If yes, how often, and for what reason?

Do you use sleeping aids in order to get a sound sleep?

Yes No

If yes, please explain: (medications, CPAP, mouth appliances, nasal strips, sound therapy, light therapy, other)

Do you snore?

Yes No

Have you been diagnosed with sleep apnea or have you ever been told that you stop breathing for periods of time while you are sleeping?

Yes No

If yes, please explain

Do you wake up feeling refreshed?

Yes No

If no, please explain

Emotional Factors: (check all that apply and explain below)

a. Negative attitude

b. Anxious

c. Depressed

d. Frustrated

e. Nervous

f. Fatigue

g. Job Stress

h. Personal problems

Additional Factors

List all allergies

List of medication

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)

Non-prescription medications, vitamins, supplements, etc

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

Describe duties at your place of employment.

Do your work responsibilities include any of the following (check all that apply)

Prolonged computer use

Heavy lifting

Prolonged standing

Extended driving

Awkward body positioning

Prolonged phone use

Please list your leisure time activities, hobbies, and physical activities:

Musculoskeletal

Osteoarthritis

Rheumatoid

Fibromyalgia

Other

If Other, Please Specify

Circulatory

Vascular Disease

Heart Disease

Blood Disorders

Ear Nose Throat

Surgical History

Sinusitis

Yes No

Other

Headache

Yes No

Have your headaches ever been diagnosed as

Migraine

Cluster

Tension

Other

If other, Please specify

How often

Times / Week

Daily

Other

If other, Please specify

Duration of episodes

locations

Is there a pattern to onset

On rising

Late Afternoon

Waken in night

Menses

weather Related

Response to medications

In recent months have the headaches:

Headaches associated with

Nausea

Blurred vision

Excessive tearing

Toothache

If toothache, which teeth?

Other associated Symptoms

Muscle Aches

Neck Pain

None

Mild

Moderate

Severe

Intermittent

Constant

Location of Neck Pain (if applicable)

Front

Back

Left

Right

Add additional Muscle Ache

Numbness or diminished sensation in:

Fingers

Yes No

Describe

Hands

Yes No

Describe

Arms

Yes No

Describe

Elsewhere

Yes No

Describe

Oral / Facial:

Jaws clenched upon awakening

Yes No

Clenching & grinding during sleep

Yes No

Clenching & grinding during waking hours

Yes No

Facial muscle fatigue

Yes No

If yes, Describe

Facial muscle pain

Yes No

If yes, Describe

Nasopharyngeal (nose/throat):

Chronic Sinusitis

Chronic stuffy nose

Chronic nasal discharge

Post nasal drip

Do you suffer from allergies?

Yes No

If yes, Which one?

Do you receive allergy shots or medications?

Yes No

If yes, Please describe

Are your nasopharyngeal allergy symptoms?

Constant

Intermittent

Seasonal

EAR:

Tinnitus

Ear Pain

Stuffiness Sensation

Loss in hearing acuity

First noticed change

Worsening

Same

Vertigo (feeling of moving around in space or objects spinning around you):

Yes No

If yes, When?

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