TMJ & Facial Pain Questionnaire

Please enable JavaScript in your browser to complete this form.

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
2. Tick the boxes below relating to the location of your pain:
RightLeft
TMJ (jaw joint)
Right
Left
Upper jaw
Right
Left
Lower jaw
Right
Left
Head
Right
Left
Temple
Right
Left
Neck
Right
Left
Shoulder
Right
Left
Ear
Right
Left
Face
Right
Left
Eye
Right
Left
Teeth
Right
Left
Cheek
Right
Left
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?
10. Do you expereince any of the following noises in your jaw joints?
RightLeft
Popping
Right
Left
Clicking
Right
Left
Grinding
Right
Left
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?
16. Do you have a history of any of the following?
YesNo
Osteoarthritis
Yes
No
Rheumatoid Arthritis
Yes
No
Psoriatic Arthritis
Yes
No
Recurrent painful joints
Yes
No
17. Do you suffer from hyperflexible joints?

Please indicate what treatments you have had:

A. Medications
B. Conservative Treatments
C. Invasive Treatments