TMJ Questionnaire

Name*

Date*

Chief Complaint*

Date of Onset*

Pain Symptoms

Do you get headaches*

Y
N
Unsure

Do you get migraine headaches?*

Y
N
Unsure

Do you frequently have neck aches or stiff neck muscles?*

Y
N
Unsure

Have you ever had chronic shoulder or back pain?*

Y
N
Unsure

Do you have trouble sleeping soundly?*

Y
N
Unsure

Are your jaws tired when you awaken?*

Y
N
Unsure

Are your teeth sore when you awaken?*

Y
N
Unsure

Are your wisdom teeth extracted?*

Y
N
Unsure

What medication(s), if any, are you taking?*

Trauma or Accidents

Have you ever had a severe blow to the head or jaw?*

Y
N
Unsure

Any whiplash neck injuries?*

Y
N
Unsure

Jaw Joints Symptoms

Does your jaw feel tired after a big meal?*

Y
N
Unsure

Are there any foods you avoid eating?*

Y
N
Unsure

Do you ever get dizzy?*

Y
N
Unsure

Do you ever feel faint?*

Y
N
Unsure

Do you ever feel nauseated (sick)?*

Y
N
Unsure

Is there a family history of jaw joint (TMJ) problems or headaches?*

Y
N
Unsure

Ear and Eye Symptoms

Do you have any pain in your ears?*

Y
N
Unsure

Do you suffer from any loss of hearing?*

Y
N
Unsure

Do you have itchiness or stuffiness in either ear?*

Y
N
Unsure

Do you hear ringing, buzzing or hissing sounds in either ear?*

Y
N
Unsure

Breathing

Do you have allergies?*

Y
N
Unsure

Do you have sinus problems?*

Y
N
Unsure

Do you have snore at night?*

Y
N
Unsure

Do you get headaches in right or left temple areas?*

Y
N
Unsure

Do you get headaches in the front or back of your head?*

Y
N
Unsure

Do you clench your teeth during the day?*

Y
N
Unsure

Do you clench your teeth during the night?*

Y
N
Unsure

Do you grind your teeth when asleep?*

Y
N
Unsure

When are your symptoms worse?*

Does anything make you feel better?*

How often do you take medication for relief of pain?*

Have you ever been involved in any serious accidents, such as a car accident?*

Y
N
Unsure

Details

Do you feel or hear a ‘clicking’, ‘popping’ or ‘cracking’ noise from either jaw joint?*

Y
N
Unsure

Has your jaw ever locked when you were unable to open or close?*

Y
N
Unsure

Do you have difficulty opening wide or yawning?*

Y
N
Unsure

Have you ever had pain in either jaw joint?*

Y
N
Unsure

Does your jaw ache when you open wide?*

Y
N
Unsure

Are there times when your eyesight blurs?*

Y
N
Unsure

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

Y
N
Unsure

Is your nose stuffed when you don’t have a cold?*

Y
N
Unsure

Have you been diagnosed with Sleep Apnea?*

Y
N
Unsure

Have you had a sleep study done at a Sleep Clinic (hospital)?*

Y
N
Unsure

Phone

This field is for validation purposes and should be left unchanged.

(425) 776-3352

TMJ Health Questionnaire

Pain Symptoms

Trauma or Accidents

Jaw Joints Symptoms

Ear and Eye Symptoms

Breathing

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