myTMJ — TMJ & Facial Pain Problem Questionnaire

1) Patient Information

Patient name * Email address * Age Date * Referred by

2) Current Problems

Describe your pain

3) Draw Where You Hurt

Tap Pencil, then draw in red on any image. Use Undo or Clear to erase. Turn Pencil OFF when done so you can scroll normally.

4) Duration & Quality

How long have you had this pain? Is the pain constant?

Quality (check all that apply)

Rate your pain (0 = none, 10 = worst)

012345678910

Pain Level: 0/10

When is pain the worst?

Morning Afternoon Evening Night

What makes the pain better? What makes the pain worse?

6) Medications

Current or previous medications for your pain (up to 10)

7) Jaw Function — noises & chewing

Does it hurt to chew? Does it hurt to open wide?

Popping side Clicking side

Other joint noises side What noises?

8) Locking / Dislocation

Has your jaw ever locked? Did it lock open or closed?

When did this first happen? When did this last happen?

Has your jaw slipped out of place? Which side?

9) Bite Changes & Asymmetry

Have you noticed a change in your bite? Describe

Change at front teeth? Change at back teeth?

Has your profile changed? Jaw crookedness / asymmetry?

When did you notice asymmetry?

10) Teeth & Habits

Are your teeth sore or sensitive? Do you clench your teeth?

Do you grind your teeth? During the day or night?

When did this start?

11) Ear-Related Symptoms

Dizziness Ringing Hearing Other

12) Accident-Related?

Is this condition due to an accident? If yes, date

Please describe

13) Blow to the Jaw

Ever injured by a blow to the jaw? When (year)

Please describe

14) Awareness of Clenching/Grinding

Are you aware if you grind/clench at night? During the day?

15–18) Sleep, Stress, and Conditions

Trouble getting to sleep? Do you sleep well?

Under a lot of stress? Nervous or anxious?

Nervous stomach / ulcers / skin disease? Arthritis (type)

Does pain keep you from doing anything? If yes, what?

19) Prior TMJ Treatments

Treatment	Used?	When	Did it help?
Splint
Night guard
Bite adjustment
Orthodontics
Medication
Physical Therapy
Counseling
Surgery
Other

If Other, please describe

20) Attestation & Signature

I have completed the above questionnaire to the best of my knowledge.

Signature date * Typed signature (optional)

Please sign here *

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