TMJ Disorder Patient History Form
Personal Information
Full Name
Date of Birth
Phone Number
Email
Address
Chief Complaint
Describe your main TMJ-related problem:
Medical History
Primary Care Physician
List any medical conditions:
Current medications (include dose & frequency):
Allergies:
TMJ Symptoms
Have you experienced any of the following? (Check all that apply)
Jaw pain
Jaw clicking/popping
Jaw locking
Facial pain
Headaches
Ear pain
Difficulty chewing
Limited mouth opening
Tooth pain
Other symptoms:
Symptom Details
When did your symptoms begin?
What seems to improve or worsen your symptoms?
Previous treatments tried (medication, splint, physiotherapy, surgery, etc):
Dental history (recent dental work, orthodontics, trauma):
Behavioral/Parafunctional Habits
Teeth grinding (bruxism)
Jaw clenching
Nail biting
Gum chewing
Cheek/lip biting
If yes, frequency:
Additional Notes
Any additional information relevant to your TMJ problem:
Signature
Date
Patient Signature