Temporomandibular Joint Disorder Patient Questionnaire
This questionnaire may take 10-15 minutes to complete
Please check all symptoms you are currently experiencing:
Please rate your current pain level (0 = no pain, 10 = worst pain imaginable):
When is your pain / discomfort worst?
How much do your jaw symptoms interfere with:
PAIN MANAGEMENT AND TREATMENT HISTORY
Have you previously been diagnosed with TMJ disorder or TMD?*
What treatments have you tried in the past? (Check all that apply and rate effectiveness: 1=Not helpful, 5=Very helpful)
TMJ arthroscopy or surgery
Stress management/counselling
Are you currently using any appliances?
Have you been told you grind or clench your teeth?*
Do you wake with tooth pain or jaw soreness?*
Have you experienced any trauma to your jaw, face, or head?*
Have you experienced whiplash or neck injury?*
Behavioral & Parafunctional Habits
Please list all relevant medical conditions:
Relevant conditions (check if applicable)
Do you have difficulty relaxing?*
Do you feel rested upon waking?*
Have you experienced any recent major life changes?*
