Name*Date* MM slash DD slash YYYY Please describe your jaw joint pain: pain, noise, limitation of movementPlease help us assess your pain (Scale 1 - 10)1 = Pain Free 10 = Horrible PainFrequency Daily Weekly Monthly Any patterns of pain?When was your first episode?What caused the problem (trauma, stress, life changes)?Are you taking any medication for your jaw problem? Yes No If so, what type?Who prescribed?Is the medication effective?Have you had any dental appliances prescribed? Yes No If so, what type?Who prescribed/made it?Is the appliance effective?Previous HistoryHave you ever been examined for a jaw joint problem before? Yes No If you answered yes to the question above, please answer the following:What was the nature of the problem? Pain, noise, limitation of movementWhat was the duration of the problem?Is the problem getting: Better Worse The same Have you ever had physical therapy for TMJ? Yes No If yes, by whom?When?Is there any additional information that can help us to understand your problem?CAPTCHAEmailThis field is for validation purposes and should be left unchanged.
