TMJ Health Questionnaire

Pain Symptoms

What is your chief concern?

Date of Onset

When are your pain symptoms the worst?

Does anything make you feel better?

How often do you take medication for the relief of pain?

What medications, if any, are you taking?

Add Medication

Trauma or Accidents

Have you ever had a severe blow to the head or jaw?

Yes No

Any whiplash neck injuries?

Yes No

Have you ever been involved in any serious accidents, such as a car accident?

Yes No

If "Yes", please add accidents/incidents below:

Add Accident/Incident

Jaw Joint Symptoms

Ear & Eye Symptoms

Please check any of the following that you ARE suffering from: By checking the box, you are answering the question as "Yes"

Do you wear glasses or contacts?

Are there times when your eyesight blurs?

Do you get pain in, around or behind either eye?

Right Eye

Left Eye

Do you have pain in either ear?

Right Ear

Left Ear

Do you suffer from any loss of hearing?

Right Ear

Left Ear

Do you have itchiness or stuffiness in either ear?

Right Ear

Left Ear

Do you hear ringing, buzzing or hissing sounds in either ear?

Right Ear

Left Ear

Breathing

Please check any of the following that you ARE suffering from: By checking the box, you are answering the question as "Yes"

Do you have allergies?

Do you have sinus problems?

Do you snore at night?

Is your nose stuffed when you don't have a cold?

Have you been diagnosed with sleep apnea?

Have you had a sleep study done at a sleep clinic or hospital?

Yes No

If "Yes", when?

Authorization

To the best of my knowledge, the above information is complete and correct. I understand tha it is my responsibility to inform the doctor if I, or my minor child, ever have a change in health.

Patient Name

Today's Date

Parent or Legal Guardian

Relationship to Patient

I request that my signature be represented by the above electronic signature and consent to recipients of electronic documents that I sign receiving personal information about me, including my email and IP addresses.

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TMJ Health Questionnaire

Pain Symptoms

Trauma or Accidents

Jaw Joint Symptoms

Ear & Eye Symptoms

Breathing

Authorization

Kewaskum Family Dentistry