TMJ | HWH Orthodontics (hwh) Step 1 of 4 - Patient Information 25% TMJ QuestionnaireTemporomandibular disorder health history form for patients.Patient's Name * Required First Middle Initial Last Birthdate * RequiredMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920What problems do you have with your jaw joints, jaw muscles, and/or teeth? * RequiredWhen did these problems start? * RequiredWhat do you think caused these problems? * RequiredDo you have medical insurance? * RequiredYesNo Insurance InformationPolicy Owner Name * RequiredPolicy Owner Birthdate * RequiredMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Relationship to PatientPolicy Owner's Address * Required Street Address Address Line 2 City StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Policy Owner Phone * RequiredPolicy Owner EmployerInsurance Company Name * RequiredInsurance Phone * RequiredGroup Number * RequiredID Number * Required Patient Symptoms: Jaw Join Problems Please check each symptom that applies.Joint clicking or popping Left Side Right Side CommentsGrating Noises Left Side Right Side CommentsJaw locks open Left Side Right Side CommentsJaw locks closed Left Side Right Side CommentsLimited jaw opening Left Side Right Side CommentsJaw does not open smoothly Left Side Right Side CommentsSoreness of jaw joints Left Side Right Side CommentsSoreness of face muscles Left Side Right Side CommentsPatient Symptoms: Teeth Problems Please check each symptom that applies.Teeth Grinding Left Side Right Side CommentsTeeth clenching Left Side Right Side CommentsSoreness of one or more teeth Left Side Right Side CommentsLooseness of one or more teeth Left Side Right Side CommentsPatient 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 earYesNoCommentsRinging or buzzingYesNoCommentsClogged or stuffy earsYesNoCommentsDiminished hearingYesNoCommentsDizziness or vertigoYesNoCommentsPoor sense of balanceYesNoCommentsPatient Symptoms: Ear or Balance Problems Please check each symptom that applies.Swallowing difficultyYesNoCommentsThroat tightnessYesNoCommentsThroat sorenessYesNoCommentsLaryngitisYesNoCommentsVoice fluctuationsYesNoCommentsThroat congestionYesNoCommentsFrequent coughYesNoCommentsFrequent throat clearingYesNoCommentsExcessive salivationYesNoCommentsTongue painYesNoCommentsPain in roof of mouthYesNoCommentsPatient Symptoms: Neck and Shoulder Pain Please check each symptom that applies.Neck, shoulder, or back painYesNoCommentsNeck, shoulder, or back reduced mobilityYesNoCommentsFrequent neck muscle fatigueYesNoCommentsArm or finger tingling, numbness, painYesNoCommentsPatient Symptoms: Eye Problems Please check each symptom that applies.Pain around or behind eyesYesNoCommentsBloodshot eyesYesNoCommentsBlurred visionYesNoCommentsPressure behind eyesYesNoCommentsLight sensitivityYesNoCommentsWatering of eyesYesNoCommentsDrooping of eyelidsYesNoComments 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?YesNoIf yes, when? * RequiredBy whom? * RequiredWas the problem the same or different than your current problem? * RequiredWhat treatment did you have before? * RequiredDo you think the previous treatment was successful? * RequiredWhat would you like your treatment here to achieve? * RequiredEmailThis field is for validation purposes and should be left unchanged.