TMJ | TEMPLATE (elevated) Step 1 of 4 - Patient Information 25% TMJ QuestionnaireTemporomandibular disorder health history form for patients.Patient's Name * Required First Middle Initial Last Birthdate * RequiredMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920What problems do you have with your jaw joints, jaw muscles, and/or teeth? * RequiredWhen did these problems start? * Required What do you think caused these problems? * Required Do you have medical insurance? * Required Yes No Insurance InformationPolicy Owner Name * Required Policy Owner Birthdate * RequiredMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Relationship to Patient Policy Owner's Address * Required Street Address Address Line 2 City StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State Zip Code Policy Owner Phone * RequiredPolicy Owner Employer Insurance Company Name * Required Insurance Phone * RequiredGroup Number * Required ID Number * Required Patient Symptoms: Jaw Join Problems Please check each symptom that applies.Joint clicking or popping Left Side Right Side Comments Grating Noises Left Side Right Side Comments Jaw locks open Left Side Right Side Comments Jaw locks closed Left Side Right Side Comments Limited jaw opening Left Side Right Side Comments Jaw does not open smoothly Left Side Right Side Comments Soreness of jaw joints Left Side Right Side Comments Soreness of face muscles Left Side Right Side Comments Patient Symptoms: Teeth Problems Please check each symptom that applies.Teeth Grinding Left Side Right Side Comments Teeth clenching Left Side Right Side Comments Soreness of one or more teeth Left Side Right Side Comments Looseness of one or more teeth Left Side Right Side Comments Patient Symptoms: Head and Facial Pain Please check each symptom that applies.Migraine type headache Left Side Right Side Cluster headaches Left Side Right Side Sinus headaches Left Side Right Side Headaches in back of head Left Side Right Side Hair and/or scalp painful to touch Left Side Right Side Degree of Pain: Head and FacialNo painSlightMildModerateSevereWorst PainMigraine type headacheCluster headachesSinus headachesHeadaches in back of headHair and/or scalp painful to touchPlease describe where you have pain and where it is the most severe.Patient Symptoms: Ear or Balance Problems Please check each symptom that applies.Pain in ear Yes No Comments Ringing or buzzing Yes No Comments Clogged or stuffy ears Yes No Comments Diminished hearing Yes No Comments Dizziness or vertigo Yes No Comments Poor sense of balance Yes No Comments Patient Symptoms: Ear or Balance Problems Please check each symptom that applies.Swallowing difficulty Yes No Comments Throat tightness Yes No Comments Throat soreness Yes No Comments Laryngitis Yes No Comments Voice fluctuations Yes No Comments Throat congestion Yes No Comments Frequent cough Yes No Comments Frequent throat clearing Yes No Comments Excessive salivation Yes No Comments Tongue pain Yes No Comments Pain in roof of mouth Yes No Comments Patient Symptoms: Neck and Shoulder Pain Please check each symptom that applies.Neck, shoulder, or back pain Yes No Comments Neck, shoulder, or back reduced mobility Yes No Comments Frequent neck muscle fatigue Yes No Comments Arm or finger tingling, numbness, pain Yes No Comments Patient Symptoms: Eye Problems Please check each symptom that applies.Pain around or behind eyes Yes No Comments Bloodshot eyes Yes No Comments Blurred vision Yes No Comments Pressure behind eyes Yes No Comments Light sensitivity Yes No Comments Watering of eyes Yes No Comments Drooping of eyelids Yes No Comments 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 PhoneThis field is for validation purposes and should be left unchanged.