TMJ Disorder Patient Questionnaire
Personal Information
Full Name
Date of Birth
Phone Number
Email
Medical History
How long have you experienced jaw problems or pain?
Have you had any previous treatment for TMJ disorder?
Yes
No
If yes, please describe the treatment:
Please list any other medical conditions you have:
Symptoms
Which of the following symptoms do you experience? (check all that apply)
Jaw pain
Clicking or popping noises
Locking of the jaw
Headaches
Ear pain
Difficulty chewing
Other symptoms:
Pain Assessment
On a scale of 0-10, what is your average jaw pain?
Where is the pain located?
How often do you experience pain?
What activities trigger your jaw pain?
Lifestyle & Habits
Do you clench or grind your teeth?
Yes
No
Unsure
Do you have any history of jaw injury?
Yes
No
If yes, please provide details:
Additional Notes
Please provide any other information that may help us with your assessment: