02 9601 5111
02 9601 5111

TMJ & Facial Pain Questionnaire

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Please complete this questionnaire prior to your consultation with the surgeon. Answer all questions to the best of your ability. The more accurate your responses the better the diagnosis and treatment offered.

If you do not yet have an appointment at Oral Facial & Implant Surgery, please call us on 0296015111 after completing this form
Name
Selected Value: 0
Please drag to indicate (0 = extremely comfortable, 10 = extremely distressing)
Selected Value: 0
Please drag to indicate (0 = extremely comfortable, 10 = extremely distressing)
6. What words best describe your pain?
7. Which of the following activities are likely to trigger or aggravate your pain?
8. How long does your pain last for once triggered?
9. When is your pain and symptoms at its worst?
11. Do you experience any of the following?
12. Do you experience any jaw locking?
13. Do you experience any of the following noises in your ear?
14. Do any of the following contribute to your pain?
15. What previous investigations have you had?
17. Do you suffer from hyperflexible joints?

Please indicate what treatments you have had:

A. Medications
B. Conservative Treatments
C. Invasive Treatments