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Dr Jacob de Looze
Oral and Maxillofacial Surgeon

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07 3395 0099

TEETH : JAW : APNOEA : IMPLANTS

Temporomandibular Joint Disorder Patient Questionnaire

This questionnaire may take 10-15 minutes to complete

Patient Information

First name

Last name

Birthday

Day

Month

Year

Phone

Medical Concern

What is your main concern regarding your jaw today?*

When did your symptoms first begin?

CURRENT SYMPTOMS

Please check all symptoms you are currently experiencing:

Jaw pain

Jaw locking (open or closed)

Jaw clicking or popping

Limited mouth opening

Difficulty chewing

Ear pain or fullness

Headaches

Neck or shoulder pain

Facial pain

Jaw muscle tenderness

Pain when yawning

Jaw deviation when opening

Tooth sensitivity or pain

Ringing in ears (tinnitus)

Dizziness

Please rate your current pain level (0 = no pain, 10 = worst pain imaginable):

At rest:

With function (eating, talking):

At its worst:

When is your pain / discomfort worst?

Morning upon waking

During the day

Evening / night

During meals

During stress

No pattern

Does the pain radiate anywhere? If yes, where?

FUNCTIONAL IMPACT

How much do your jaw symptoms interfere with:

Daily Activities*

Not at all

Slightly

Moderately

Severely

Eating*

Not at all

Slightly

Moderately

Severely

Speaking*

Not at all

Slightly

Moderately

Severely

Sleep*

Not at all

Slightly

Moderately

Severely

Work/School*

Not at all

Slightly

Moderately

Severely

Social activities*

Not at all

Slightly

Moderately

Severely

What foods do you avoid due to jaw problems?*

PAIN MANAGEMENT AND TREATMENT HISTORY

Have you previously been diagnosed with TMJ disorder or TMD?*

Yes

No

If YES, by whom?

What treatments have you tried in the past? (Check all that apply and rate effectiveness: 1=Not helpful, 5=Very helpful)

Physical Therapy

Oral splint/night guard

Medications

Botox injections

TMJ arthroscopy or surgery

Chiropractic care

Acupuncture

Massage therapy

Heat/ice therapy

Dietary modifications

Stress management/counselling

Other

Are you currently using any appliances?

How often do you wear it?

List any current medications for TMJ/pain

Are you currently seeing any other healthcare providers for this condition?*

Dental History

Do you have:

Missing teeth

Dentures (partial / complete)

Dental Implants

Crowns or bridges

Recent dental work (past 6 months)

Describe any dental work (if any):

Malocclusion (misaligned bite)

Orthodontic treatment (past / present)

Have you been told you grind or clench your teeth?*

Yes

No

Do you wake with tooth pain or jaw soreness?*

Yes

No

Trauma History

Have you experienced any trauma to your jaw, face, or head?*

Yes

No

If YES: provide details below

Have you experienced whiplash or neck injury?*

Yes

No

Behavioral & Parafunctional Habits

Do you:

Clench your jaw during the day

Grind your teeth at night

Bite your nails

Chew gum regularly

Chew on pens, pencils, or other objects

Rest your chin on your hand frequently

Hold a phone between shoulder and ear throughout the day

Bite your cheeks or lips

How many hours per day do you spend on a computer:

Medical History

Please list all relevant medical conditions:

Medical conditions

Relevant conditions (check if applicable)

Arthritis (osteoarthritis, rheumatoid, psoriatic)

Fibromyalgia

Chronic fatigue syndrome

Autoimmune conditions

Chronic pain conditions

Depression or anxiety

Sleep apnea or sleep disorders

Migraine or chronic headaches

Cervical spine problems

This is a checkbox.

Previous head/neck cancer

Connective tissue disorders (Ehlers-Danlos, etc.)

Psychosocial Factors

Current stress level (0- none, 10-extreme)*

Major stressors in your life:

Do you have difficulty relaxing?*

Sleep Quality*

Average hours of sleep per night*

Do you feel rested upon waking?*

Have you experienced any recent major life changes?*

What does successful treatment looklike to you?*

Is there anything else you would like me to know about your condition?

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