General Information

    PATIENT INFORMATION

    Patient Name

    Email*

    Questionnaire

    Describe, in as much detail as you can, your main concerns regarding your jaw joints:

    Please list any other medical or dental specialists who are involved in your regular medical and dental care:

    What treatment modalities (physiotherapy, chiropractic, acupuncture, etc.) and medications have you been using to manage you condition up to this point:

    Please write a brief narrative of your past medical and dental history (including injuries) pertaining to your jaw joints:

    Do you have a grating, clicking or popping sound in either, or both jaw joints when chewing?

    Do you have sensations or stiffness, pressure or blockage, ringing, hissing or buzzing in your ears?

    Do you ever feel dizzy or faint?

    Is your jaw painful or locked when you wake up in the morning?

    Do you consider yourself chronically fatigued?

    Are you ever nauseated for no apparent reason?

    Do your fingers sometimes go numb?

    Check any area where you have pain or soreness:

    Jaw JointsUpper jaw or teethBack of headForeheadLower jaw or teethChewing musclesTemplesSide of neckBehind the eyesTongueOther

    If Other, describe:

    Is it hard to move your jaw side-to-side, forward or backward?

    Do you have difficulty chewing?

    Do you have back teeth missing?

    Have you had extensive dental crowns and bridgework?

    Do you clench your teeth during the day?

    Do you grind your teeth at night? (Ask someone else if you are unsure)

    Do you ever have a headache when you wake up?

    Have you had a whiplash injury?

    Have you worn a cervical collar or had neck traction?

    Have you ever had a blow to the chin, face or head?

    Have you reached the point at which drugs no longer relieve your symptoms?

    Does chewing gum initiate your symptoms?

    Does your jaw deviate to the left or right when you open wide?

    When your mouth is open, can you insert three fingers into your mouth vertically?

    Has your jaw ever locked open or closed?