Temporomandibular Joint (TMJ) Questionnaire

QUESTIONS TO SEE IF YOU MIGHT HAVE A TMJ PROBLEM:

Answer Yes or No to the following questions to see if you might have a TMJ problem.  You can print the form, circle your answers, and bring the completed form to our office for your TMJ appointment.

 

 

1.	Do you have frequent headaches?	Y	N
2.	Do you hear popping, clicking or cracking sounds when you chew?	Y	N
3.	Do you hear a grating sound (like crumpling of newspaper) when you chew?	Y	N
4.	Do you have stuffiness, pressure or blockage in your ears?	Y	N
5.	Do you hear a ringing or buzzing sound in either or both of your ears?	Y	N
6.	Do you experience dizziness frequently?	Y	N
7.	Do your jaws feel like they "catch?"	Y	N
8.	Do your jaws feel tight, difficult to open?	Y	N
9.	Does it appear that you can't open your mouth as wide as you used to?	Y	N
10.	Does you tongue go between your teeth or do you bite on your tongue to separate your teeth?	Y	N
11.	Do your teeth ache?	Y	N
12.	Are your teeth sensitive, especially to cold temperatures?	Y	N
13.	Do you wake with sore facial muscles?	Y	N
14.	Do you clench or grind your teeth during movements of frustration or concentration?	Y	N
15.	Do you grind your teeth at night?	Y	N
16.	Do your ears hurt?	Y	N
17.	Does it hurt to move your jaw sideways?	Y	N
18.	Do your neck, back of your head, or shoulder hurt?	Y	N
19.	Have you been hit in the jaw?	Y	N
20.	Have you been put to sleep for surgery?	Y	N
21.	Have you had a whiplash injury?	Y	N
22.	Have you seen a neurologist, psychologist or psychiatrist for unexplained head or neck pain?	Y	N
23.	Do your jaws ache after eating?	Y	N
24.	Are you under a lot of stress?	Y	N
25.	Have you been told that you might have TMJ?	Y	N

If you have three or more of these symptoms or any questions regarding TMJ  disorders (TMD) please call our office at (408) 578-5595.