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02 9601 5111
02 9601 5111
Surgeons
Patient portal
Your initial appointment
Online registration
TMJ & Facial Pain Questionnaire
Orthognathic Surgery Questionnaire
Online Referral
Dental Extractions
Wisdom Teeth
Orthognathic Surgery
Dental Implants
Facial Reconstruction Surgery
Oral Pathology
Surgeons
Patient portal
Your initial appointment
Online registration
TMJ & Facial Pain Questionnaire
Orthognathic Surgery Questionnaire
Online Referral
Dental Extractions
Wisdom Teeth
Orthognathic Surgery
Dental Implants
Facial Reconstruction Surgery
Oral Pathology
Home
Procedures
Dental Extractions
Wisdom Teeth
Orthognathic Surgery
Dental Implants
Facial Reconstruction Surgery
Sinus Lift & Bone Grafting
Oral pathology
Our Surgeons
Patient Portal
Your initial appointment
online registration
TMJ & Facial Pain Questionnaire
Orthognathic Surgery Questionnaire
Postoperative Instructions
Hospital Pre-Admission Forms
Online Referral
More
About Us
Contact Us
FAQs
X
TMJ & Facial Pain Questionnaire
Please enable JavaScript in your browser to complete this form.
Please enable JavaScript in your browser to complete this form.
THIS FORM ONLY NEEDS TO BE COMPLETED IF YOU HAVE BEEN REFERRED FOR TMJ, JAW JOINT OR FACIAL PAIN. 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
Date
*
Name
*
First
Last
Phone
*
Date of Birth
1. In your own words describe your problem:
*
2. Tick the boxes below relating to the location of your pain:
Right
Left
TMJ (jaw joint)
Right
TMJ (jaw joint) Right
Left
TMJ (jaw joint) Left
Upper jaw
Right
Upper jaw Right
Left
Upper jaw Left
Lower jaw
Right
Lower jaw Right
Left
Lower jaw Left
Head
Right
Head Right
Left
Head Left
Temple
Right
Temple Right
Left
Temple Left
Neck
Right
Neck Right
Left
Neck Left
Shoulder
Right
Shoulder Right
Left
Shoulder Left
Ear
Right
Ear Right
Left
Ear Left
Face
Right
Face Right
Left
Face Left
Eye
Right
Eye Right
Left
Eye Left
Teeth
Right
Teeth Right
Left
Teeth Left
Cheek
Right
Cheek Right
Left
Cheek Left
3. How severe is the pain most of the time?
Selected Value:
0
Please drag to indicate (0 = extremely comfortable, 10 = extremely distressing)
4. How severe is the pain at its worst?
Selected Value:
0
Please drag to indicate (0 = extremely comfortable, 10 = extremely distressing)
5. How long have your pain symptoms been present for?
*
6. What words best describe your pain?
*
Sharp
Dull
Aching
Deep
Superficial
Burning
Pulsing
Spreading
Electric
7. Which of the following activities are likely to trigger or aggravate your pain?
*
Speaking
Opening mouth wide
Biting into an apple
Chewing hard foods
Clenching jaw
Washing your face
Brushing your teeth
Touching a specific part of your face
Wind blowing on your face
Shaving
None of the above
8. How long does your pain last for once triggered?
*
a few seconds
minutes
up to an hour
multiple hours
a day or longer
not applicable
9. When is your pain and symptoms at its worst?
*
First thing in the morning
During the day
End of day / evening
While sleeping
None of the above
10. Do you expereince any of the following noises in your jaw joints?
Right
Left
Popping
Right
Popping Right
Left
Popping Left
Clicking
Right
Clicking Right
Left
Clicking Left
Grinding
Right
Grinding Right
Left
Grinding Left
11. Do you experience any of the following?
*
Intermittent limitation with mouth opening
Difficulty opening your mouth
Constant limitation with mouth opening
Difficulty closing your mouth
Blocked ears
Dizziness
Numbness
None of the above
12. Do you experience any jaw locking?
*
Locked open
Locked close
No locking
13. Do you experience any of the following noises in your ear?
*
Whooshing
Throbbing
Clicking
Grinding
Ringing
None of the above
14. Do any of the following contribute to your pain?
*
Bruxism (teeth grinding)
Jaw clenching habit
Arthritis
Stress
Trauma to jaw / face
None of the above
15. What previous investigations have you had?
Radiographs/xrays
CT scan
MRI scan
None
Other
please specify:
*
16. Do you have a history of any of the following?
*
Yes
No
Osteoarthritis
Yes
Osteoarthritis Yes
No
Osteoarthritis No
Rheumatoid Arthritis
Yes
Rheumatoid Arthritis Yes
No
Rheumatoid Arthritis No
Psoriatic Arthritis
Yes
Psoriatic Arthritis Yes
No
Psoriatic Arthritis No
Recurrent painful joints
Yes
Recurrent painful joints Yes
No
Recurrent painful joints No
17. Do you suffer from hyperflexible joints?
*
Yes
No
Unsure
Please indicate what treatments you have had:
A. Medications
Anti-inflammatories (Nurofen, Ipufren, Advil, Diclofenac)
Panadol (Paracetamol)
Steroids
Muscle relaxers
Other
please specify:
*
B. Conservative Treatments
Occlusal (bite) splint therapy
Physical therapy including massage
Transcutaneous electrical nerve stimulation
Orthodontics
Injections (including botox)
Other
please specify:
*
C. Invasive Treatments
Teeth and bite adjusted by your dentist
Arthroscopy or arthrocentesis
Open TMJ surgery or arthroplasty
Orthognathic (jaw) surgery
Other
please specify:
*
Is there anything else you would like to add?
Email
Submit