Patient Name(Required) Date MM slash DD slash YYYY Rate these Symptoms from 0 (not significant or not applicable) - 10 (very Significant)Headaches 0 1 2 3 4 5 6 7 8 9 10 TMJ Pain 0 1 2 3 4 5 6 7 8 9 10 TMJ Noise 0 1 2 3 4 5 6 7 8 9 10 Limited Jaw Opening 0 1 2 3 4 5 6 7 8 9 10 Ear Pain/Congestion 0 1 2 3 4 5 6 7 8 9 10 Vertigo (dizziness) 0 1 2 3 4 5 6 7 8 9 10 Tinnitus 0 1 2 3 4 5 6 7 8 9 10 Dysphagia (difficulty swallowing) 0 1 2 3 4 5 6 7 8 9 10 Clenching 0 1 2 3 4 5 6 7 8 9 10 Bruxing (teeth grinding) 0 1 2 3 4 5 6 7 8 9 10 Pain in Temples 0 1 2 3 4 5 6 7 8 9 10 Facial Pain 0 1 2 3 4 5 6 7 8 9 10 Tender/Sensitive Teeth 0 1 2 3 4 5 6 7 8 9 10 Difficulty Chewing 0 1 2 3 4 5 6 7 8 9 10 Upper Cervical Pain (neck) 0 1 2 3 4 5 6 7 8 9 10 Postural Problems 0 1 2 3 4 5 6 7 8 9 10 Paresthesia of Fingertips (tingling) 0 1 2 3 4 5 6 7 8 9 10 Nervousness/Anxiety 0 1 2 3 4 5 6 7 8 9 10 Insomnia 0 1 2 3 4 5 6 7 8 9 10 Facial Asymmetry 0 1 2 3 4 5 6 7 8 9 10 Poor Facial Profile 0 1 2 3 4 5 6 7 8 9 10 Forward Head Posture 0 1 2 3 4 5 6 7 8 9 10 Facial Edema (swelling) 0 1 2 3 4 5 6 7 8 9 10 Chipped/Worn Down Teeth 0 1 2 3 4 5 6 7 8 9 10 Snoring 0 1 2 3 4 5 6 7 8 9 10 Sleep Quality ( 0 poor - 10 excellent ) 0 1 2 3 4 5 6 7 8 9 10 Wake Up Feeling Refreshed ( 0 not refreshed - 10 very refreshed ) 0 1 2 3 4 5 6 7 8 9 10
