History of Injury & Trauma
Any childhood history of falls, accidents, or injury to the face or head?
— Yes No
If yes, please describe
Any recent history of trauma to the head or face?
— Yes No
Any activity that holds the head or jaw in an imbalanced position?
— Yes No
If yes, please describe
Have you ever been sedated (put to sleep) for surgery?
— Yes No
Facial Pain — Past Treatment
Have you ever been examined for a TMD problem before?
— Yes No
If yes, by whom and when?
What was the nature of the problem? (pain, noise, limitation of movement)
Please describe
What was the duration of the problem? (months / years)
Is this a new problem?
— Yes No
Is your pain in the morning, afternoon, or night?
Morning Afternoon Night
Is the problem getting better, worse, or staying the same?
— Better Worse Staying the same
Have you ever had physical therapy for TMD?
— Yes No
Have you ever received treatment for jaw problems?
— Yes No
If yes, by whom and when?
What was the treatment? (e.g. bite splint, orthodontics, appliances, therapy)
Have you ever had injections for your TMD (muscle relaxants such as Botox/Flexeril, cortisone, or anti-inflammatories)?
— Yes No
How many dental appliances have you worn?
Were these appliances effective?
— Yes No
Is there any additional information that can help us?
What makes it worse?
What makes it better?
Current Symptoms — Triggers
Does the pain occur on its own, or do you need to trigger it (function, touching, etc.)?
If you place a Q-tip in your left ear and push forward, does that trigger pain?
— Yes No
Can the pain be triggered by lightly brushing or pressing the skin with a Q-tip?
— Yes No
Current & Previous Habits
Do you clench your teeth together under stress?
— Yes No
Do you grind/clench your teeth at night?
— Yes No
Do you sleep with an unusual head position?
— Yes No
Are you aware of any habits or activities that may aggravate this condition?
— Yes No
Do you wake up feeling well rested?
— Yes No
Have either of your parents been diagnosed with sleep apnea in the past?
— Yes No
Do you snore?
— Yes No
Current Symptoms
For any symptom you experience, choose its severity. Leave the rest set to "None." You may add frequency and time of day where helpful.
A. Head Pain, Headaches, Facial Pain
Symptom Severity Frequency Time of day
Migraine-type headaches (L/R) None Mild Moderate Severe — Daily Monthly Yearly — Morning Afternoon Night
Cluster headaches / maxillary sinus (L/R) None Mild Moderate Severe — Daily Monthly Yearly — Morning Afternoon Night
Headaches under the eyes None Mild Moderate Severe — Daily Monthly Yearly — Morning Afternoon Night
Occipital headaches (back of head, with or without shooting pain) None Mild Moderate Severe — Daily Monthly Yearly — Morning Afternoon Night
Hair and/or scalp painful to touch None Mild Moderate Severe — Daily Monthly Yearly — Morning Afternoon Night
B. Eye Pain / Orbital Problems
Symptom Severity Frequency Time of day
Bloodshot eyes None Mild Moderate Severe — Daily Monthly Yearly — Morning Afternoon Night
Pressure behind the eyes (L/R) None Mild Moderate Severe — Daily Monthly Yearly — Morning Afternoon Night
Light sensitivity None Mild Moderate Severe — Daily Monthly Yearly — Morning Afternoon Night
C. Jaw & Jaw Joint (TMD) Problems
Symptom Severity Frequency Time of day
Clicking, popping jaw joints (L/R) None Mild Moderate Severe — Daily Monthly Yearly — Morning Afternoon Night
Grating sounds (L/R) None Mild Moderate Severe — Daily Monthly Yearly — Morning Afternoon Night
Jaw locking (opened) None Mild Moderate Severe — Daily Monthly Yearly — Morning Afternoon Night
Jaw locking (closed) None Mild Moderate Severe — Daily Monthly Yearly — Morning Afternoon Night
Uncontrollable jaw/tongue movements None Mild Moderate Severe — Daily Monthly Yearly — Morning Afternoon Night
Pain in cheek muscles None Mild Moderate Severe — Daily Monthly Yearly — Morning Afternoon Night
Reduced mobility and range of motion None Mild Moderate Severe — Daily Monthly Yearly — Morning Afternoon Night
D. Ear Problems & Postural Imbalance
Symptom Severity Frequency Time of day
Ear pain without infection None Mild Moderate Severe — Daily Monthly Yearly — Morning Afternoon Night
Clogged, stuffy, itchy ears None Mild Moderate Severe — Daily Monthly Yearly — Morning Afternoon Night
Balance problems / vertigo None Mild Moderate Severe — Daily Monthly Yearly — Morning Afternoon Night
Diminished hearing None Mild Moderate Severe — Daily Monthly Yearly — Morning Afternoon Night
Hissing, buzzing, ringing sounds None Mild Moderate Severe — Daily Monthly Yearly — Morning Afternoon Night
E. Neck & Shoulder Pain
Symptom Severity Frequency Time of day
Arm and finger tingling, numbness, pain (L/R) None Mild Moderate Severe — Daily Monthly Yearly — Morning Afternoon Night
Stiffness (L/R) None Mild Moderate Severe — Daily Monthly Yearly — Morning Afternoon Night
Neck pain (L/R) None Mild Moderate Severe — Daily Monthly Yearly — Morning Afternoon Night
Tired, sore neck muscles (L/R) None Mild Moderate Severe — Daily Monthly Yearly — Morning Afternoon Night
Back pain, upper and lower None Mild Moderate Severe — Daily Monthly Yearly — Morning Afternoon Night
Shoulder aches None Mild Moderate Severe — Daily Monthly Yearly — Morning Afternoon Night
F. Throat Problems
Symptom Severity Frequency Time of day
Swallowing difficulties None Mild Moderate Severe — Daily Monthly Yearly — Morning Afternoon Night
Tightness of throat None Mild Moderate Severe — Daily Monthly Yearly — Morning Afternoon Night
Sore throat None Mild Moderate Severe — Daily Monthly Yearly — Morning Afternoon Night
Voice fluctuations None Mild Moderate Severe — Daily Monthly Yearly — Morning Afternoon Night