TEMPORO-MANDIBULAR JOINT ASSESSMENT QUESTIONNAIRE

19 - Are you aware of an uncomfortable bite ?

Yes

No

20 - Must you chew exclusively on one side ?

Yes

No

21 - Did you ever receive a blow to the jaw (trauma) ?

Yes

No

22 - Are you a habitual gum chewer ?

Yes

No

23 - Do you have problems with your ears or hearing ?

Yes

No

24 - Has the noise/problem recently become more pronounced ? When ?

Yes

No

25 - Do you take medication or pills for pain or discomfort? Explain :

Yes

No

26 - Do you suffer from arthritis or pain in other joints ?

Yes

No

27 - Does any family member or relative have arthritis ?

Yes

No

28 - Do you have problems with other joints of your body?

Yes

No

29 - Did anything occur which might be related to the onset of this problem ? Explain :

Yes

No

30 - Has there been a stressfull event in your life recently (such as change in marital status, childbirth,change in employment, exams, desease or death in immediate family) ? Comments :

Yes

No

31 - Do you feel you are under a great deal of stress (job, family, social, school, etc.) ?

Yes

No

32 - Have you had recent dental treatment ? Explain :

Yes

No

33 - Do you take more than one alcoholic drink per day ?

Yes

No

34 - Do you smoke cigarettes, cigars or a pipe ?

Yes

No

35 - Do you bite your nails, tongue or lips ?

Yes

No

36 - Do you wear, or have you ever worn a splint, bite plate or other appliance ?

Yes

No

37 - Have you ever been treated for a bad bite ?

Yes

No

38 - Have you ever had orthodontic treatment ? When ? Where ?

Yes

No

39 - Have you ever been treated for problems of your jaw joints or facial muscle spasms ?

Yes

No

40 - Are there times when you notice that this problem or pain is less severe or gone completely ? When :

Yes

No

41 - Is there something you can do to relieve the pain or discomfort ? Explain :

Yes

No

42 - Are you afraid your problem is serious ?

Yes

No

43 - Do you feel you need treatment for this problem ?

Yes

No

TEMPORO-MANDIBULAR JOINT ASSESSMENT QUESTIONNAIRE

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