TMJ Disorder Assessment Form
Patient Name
Date of Birth
Assessment Date
Chief Complaint
Symptoms
Pain Location(s)
Jaw
Face
Neck
Ear
Temple
Pain Severity (0-10)
When does pain occur?
Opening Mouth
Chewing
At Rest
Pain Duration
Jaw Locking
None
Open
Closed
Sounds in TMJ
Clicking
Popping
Crepitus
None
Mouth Opening Limitation
Yes
No
Maximum Mouth Opening (mm)
Other Symptoms
Headache
Tinnitus
Dizziness
Ear Fullness
History
Precipitating factors
Trauma
Bruxism
Stress
Previous Treatments
Clinician Notes