Patient Symptoms Questionnaire

MM slash DD slash YYYY

0 1 2 3 4 5 6 7 8 9 10
Headaches
TMJ Pain
TMJ Noise
Limited Jaw Opening
Ear Pain
Vertigo
Tinnitus
Dysphagia (difficulty swallowing)
Clenching
Bruxing (teeth grinding)
Pain in Temples
Facial Pain
Sensitive Teeth
Difficulty Chewing
Upper Cervical Pain (neck)
Postural Problems
Paresthesia of Fingertips
Nervousness
Insomnia
Facial Asymmetry
Poor Facial Profile
Forward Head Posture
Facial Edema (swelling)
Chipped/Worn Down Teeth
Snoring
Sleep Quality
Wake Up Feeling Refreshed

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