TMJ Questionniare: For Patients/Consumers AND Their Providers

Questionnaire to Identify if TMJ Dysfunction is Contributing to Health Problems:

For YOU, the Patient/Consumer AND for Providers to Use with Consumers/Patients/Clients

Make a mark next to, highlight, or if you did not print this, make a list of which of the following apply:

PAIN SYMPTOMS

Do you get headaches?                                                              

Do you get migraines? 

Do you have neck aches or stiffness? 

Do you have shoulder or back pain? 

Do you get pain in, around or behind either eye? 

Do you have pain in either ear? 

Do you take pain medication or muscle relaxers?

TRAUMA OR ACCIDENTS 

Have you ever had a severe blow to your head, face or jaw? 

Have you had a whiplash injury to your neck? 

Have you ever been involved in a car accident?

Have you had any other serious accidents? 

Have you had any surgeries? 

JAW JOINT SYMPTOMS

Do you have pain in either jaw joint?

Have you had pain in either jaw joint in the past? 

Do you feel or hear a clicking, popping or cracking noise in either jaw joint? 

Has your jaw ever locked open or closed?

Do you have difficulty with opening your mouth wide? 

Is your jaw tired during or after chewing a big meal? 

Do you hear a grating sound in your ears when opening and closing your jaw? 

Do grind your teeth at night?

Do you grind your teeth during the day? 

Is your jaw tired in the morning when you awaken? 

Are any of your teeth sensitive or painful to chewing? 

Are your teeth sore in the morning when you awaken? 

OTHER SYMPTOMS

Do your ears feel full or congested? 

Do you ever get dizzy? 

Do you have any loss of hearing? 

Do you have trouble sleeping?

Are you tired in the morning or throughout the day? 

Do you snore or have sleep apnea? 

If you have answered yes to 6 or more of the above questions TMJ dysfunction may be a contributing factor to your problems. I hope this list is of help to you, and you will find my contact information below, so please visit my website and contact me if I can be of further assistance.