Edmonton
Sherwood Park
Home
Meet our Team
First Visit
Treatment
Smiles for Life
Orthodontic Care
Invisalign®
Living With Ortho
Contact
login
Patient Login
Patient Login
Edmonton
Sherwood Park
TMJ Form
"
*
" indicates required fields
Your Information
Name
*
First Name *
Last Name *
Email Address
*
Chief Complaint
1.
What is/are your main complaint(s):
Main Complaint 1
Left Jaw joint pain
Left Jaw joints lock open
Left Jaw joints lock closed
Left Earaches
Left Neck aches
Left Jaw Joint noises
Main Complaint 2
Right Jaw joint pain
Right Jaw joints lock open
Right Jaw joints lock closed
Right Earaches
Right Neck aches
Right Jaw Joint noises
Main Complaint 3
Limited mouth opening
Headaches
Muscle pain
Muscle stiffness
Excessive tooth wear
Other
Main Complaint 4
2.
What date did your problem start?
What date did your problem start?
DD dash MM dash YYYY
3.
Did anything trigger/precipitate your pain?
Did anything trigger/precipitate your pain?
4.
Which side is worse?
Which side is worse?
Left
Right
Both
5.
Would you call it...
Would you call it...
Uncomfortable
Painful
Suffering
6.
Is the pain...
Is the pain...
Disturbing your sleep?
Constant or recurring?
Dull or aching?
Interfering with daily activities?
A burning type of pain?
A stabbing, severe pain?
7.
What is your "pain status" today?
What is your "pain status" today?
No Pain
Medium Pain
Most Severe Pain
What was your "pain status" when it was at it’s most severe on any occasion
What was your "pain status" when it was at it’s most severe on any occasion
No Pain
Medium Pain
Most Severe Pain
8.
Can you locate a specific site of pain?
Can you locate a specific site of pain?
Yes
No
Please explain
9.
Has the severity of pain been...
Has the severity of pain been...
Increasing
Decreasing
10.
Does it hurt to...
Does it hurt to...
Open your jaw
Chew
11.
Do you hear...
Do you hear... 1
Left Joint sounds?
Left Clicking or popping joint sounds?
Left Grating or grinding type joint sounds?
Do you hear... 2
Right Joint sounds?
Right Clicking or popping joint sounds?
Right Grating or grinding type joint sounds?
12.
Did your joints have sounds in the past that have now stopped?
Did your joints have sounds in the past that have now stopped?
Yes
No
13.
Do you have difficulty opening your mouth?
Do you have difficulty opening your mouth?
Yes
No
14.
Are your jaws tired after eating a meal?
Are your jaws tired after eating a meal?
Yes
No
15.
Do you have headaches?
Do you have headaches?
Yes
No
Are the headaches related to your TMD?
Are the headaches related to your TMD?
Yes
No
16.
Is the condition worse...
Is the condition worse...
In the morning?
In the afternoon?
In the evening?
During sleep?
After eating?
After talking?
17.
Do you prefer to chew...
Do you prefer to chew...
Left
Right
Both
18.
Do you chew on...
Do you chew on...
Front Teeth
Back Teeth
19.
Do you chew exclusively on...
Do you chew exclusively on...
Left
Right
Both
20.
Do you do the following with your teeth?
Do you do the following with your teeth?
Grind
Clench
Both
Not Sure
21.
Would you consider your lifestyle stressful?
Would you consider your lifestyle stressful?
Yes
No
22.
Is your jaw pain/headaches aggravated by increased stress levels?
Is your jaw pain/headaches aggravated by increased stress levels?
Yes
No
23.
Have you ever been diagnosed with arthritis?
Have you ever been diagnosed with arthritis?
Yes
No
24.
Do you have...
Do you have...
Neck pain?
Shoulder pain?
Back pain?
25.
Do you notice...
Do you notice...
Hearing loss?
Stuffiness, plugged ears?
Headaches?
Pain in teeth?
Dizziness?
26.
Are you currently taking medications for this problem?
Are you currently taking medications for this problem?
Yes
No
Which type?
Which type?
Pain Killers
Muscle Relaxants
Antidepressants
Unsure
Dental History
1.
Have you had, or was there ever a time when you had...
Have you had, or was there ever a time when you had...
Sore teeth?
Teeth extracted?
Recent crowns or bridges?
Splint treatment or jaw pain?
Teeth straightened? (braces/Invisalign)
Badly worn teeth?
Wisdom teeth extracted?
Jaw joint x-rays?
Family history of jaw join problems?
Very loose teeth?
Recent fillings?
Jaw joint surgery?
When were your teeth straightened?
When were your teeth straightened?
DD dash MM dash YYYY
If past treatment on jaw joints, was treatment successful?
If past treatment on jaw joints, was treatment successful?
Yes
No
2.
Have you had a splint/dental guard made in the last 24 months?
Have you had a splint/dental guard made in the last 24 months?
Yes
No
Reminder: Please bring your splint/dental guard to your appointment.
Is your dental guard for
Is your dental guard for
Tooth protection from grinding?
Headaches?
Jaw pain?
Joint noises?
3.
If you would like to expand on any answer, please do so
If you would like to expand on any answer, please do so
Special Offer
I agree to receive future messages such as special offers, useful information about advancements in orthodontic treatment options, and more via email and/or SMS, Message + data rates may apply. I am able to unsubscribe at any time. Reply STOP to unsubscribe to SMS.
Δ