TMJ | WH Orthodontics (wh) – Forms – Clear Partnering Group

TMJ Questionnaire

TMJ Questionnaire
Temporomandibular disorder health history form for patients.
Patient's Name * Required
First Middle Initial Last
Birthdate * Required
What problems do you have with your jaw joints, jaw muscles, and/or teeth? * Required
When did these problems start? * Required
What do you think caused these problems? * Required
Do you have medical insurance? * Required
- Yes
- No

Insurance Information
Policy Owner Name * Required
Policy Owner Birthdate * Required
Relationship to Patient
Policy Owner's Address * Required
Street Address Address Line 2 City State Zip Code
Policy Owner Phone * Required
Policy Owner Employer
Insurance Company Name * Required
Insurance Phone * Required
Group Number * Required
ID Number * Required

Do you have any recent or childhood history of trauma to the head or face?
Including things such as falls, auto accident, blows to the head or face, sports injury, etc.? If yes, please describe:
Do you have a frequent activity that causes you to hold your head or neck in an imbalanced position?
Including things such as playing instruments, keyboard, holding phones, etc.? If yes, please describe:
Have you ever been treated for TMJ problems before?
- Yes
- No
If yes, when? * Required
By whom? * Required
Was the problem the same or different than your current problem? * Required
What treatment did you have before? * Required
Do you think the previous treatment was successful? * Required
What would you like your treatment here to achieve? * Required
Name
This field is for validation purposes and should be left unchanged.

Worst Pain

Migraine type headache

Cluster headaches

Sinus headaches

Headaches in back of head

Hair and/or scalp painful to touch