TMJ Disorder Dental Medical History Form
Personal Information
Full Name
Date of Birth
Gender
Female
Male
Other
Phone
Address
Chief Complaint
What is your primary concern regarding your TMJ/jaw?
Medical History
Are you currently under a physician's care?
Yes
No
If yes, for what condition?
List any medical conditions:
List all medications currently taken:
Allergies (medications, materials, etc.):
TMJ / Jaw Related History
Do you experience any of the following?
Jaw pain
Clicking or popping sounds
Locking of jaw
Headaches
Facial pain
Ear pain / ringing in ears
Difficulty chewing
When did your symptoms begin?
Describe any injuries to your jaw or face:
Have you had any previous treatments for TMJ?
Yes
No
If yes, please describe:
Dental History
How often do you see a dentist?
Do you have any of the following?
Grinding/clenching teeth
Tooth pain
Bite problems
Broken/Chipped teeth
Do you wear any dental appliances?
Other dental history notes:
Additional Notes
Please share anything else relevant to your TMJ or health: