TMJ QUESTIONNAIRE FORM CHIEF CONCERNDATE OF ONSETPAIN SYMPTOMSDo you get headaches? Yes No Do you get headaches in the right or left temple areas? Yes No Do you get migraine headaches? Yes No Do you get headaches in the front or back of your head? Yes No Do you frequently have neck aches or stiff neck muscles? Yes No Do you clench your teeth during the day? Yes No Have you ever had chronic shoulder or back pain? Yes No Do you clench your teeth at night? Yes No Do you have trouble sleeping soundly? Yes No Do you grind your teeth when asleep? Yes No Are your jaws tired when you awaken? Yes No When are your pain symptoms the worst?Are your teeth sore when you awaken? Yes No Does anything make you feel better?Have your wisdom teeth been extracted? Yes No How often do you take medication for relief of pain?What medications, if any, are you taking?TRAUMA or ACCIDENTSHave 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 (e.g., car accident)? Yes No DetailsJAW JOINT SYMPTOMSDoes your jaw feel tired after a big meal? Yes No Do you hear a 'clicking,' 'popping,' or 'cracking' noise from either jaw joint? Yes No Are there any foods you avoid eating? Yes No Has your jaw ever locked so you were unable to open or close? Yes No Do you ever get dizzy? Yes No Do you have difficulty opening wide or yawning? Yes No Do you ever feel faint? Yes No Have you ever had pain in either jaw joint? Yes No Do you ever feel nauseated? Yes No Does your jaw ache when you open wide? Yes No Is there a family history of jaw joint (TMJ) problems or headaches? Yes No EAR and EYE SYMPTOMSDo you have pain in either ear? Yes No Do you wear glasses or contacts? Yes No Do you suffer from any loss of hearing? Yes No Are there times when your eyesight blurs? Yes No Do you have itchiness or stuffiness in either ear? Yes No Do you get pain in, around, or behind either eye? Yes No Do you hear ringing, buzzing, or hissing sounds in either ear? Yes No BREATHINGDo you have allergies? Yes No ls your nose stuffed when you don't have a cold? Yes No Do you have sinus problems? Yes No Have you been diagnosed with Sleep Apnea? Yes No CAPTCHA Δ
