TMJ Form - Dr. Reid Friesen

Due to increased patient care needs, Dr. Friesen is currently scheduling New Patient Jaw examinations in 9-12 months. Motor Vehicle examinations are scheduling in 8 weeks. All new patients can be added to Dr. Friesen's waitlist. For patients with urgent or acute care needs, please contact our office directly at 780.463.3616

Your Information

Chief Complaint

1. What is/are your main complaint(s):

2. What date did your problem start?

3. Did anything trigger/precipitate your pain?

4. Which side is worse?

5. Would you call it...

6. Is the pain...

7. What is your "pain status" today?

What was your "pain status" when it was at it’s most severe on any occasion

8. Can you locate a specific site of pain?

9. Has the severity of pain been...

10. Does it hurt to...

11. Do you hear...

12. Did your joints have sounds in the past that have now stopped?

13. Do you have difficulty opening your mouth?

14. Are your jaws tired after eating a meal?

15. Do you have headaches?

Are the headaches related to your TMD?

16. Is the condition worse...

17. Do you prefer to chew...

18. Do you chew on...

19. Do you chew exclusively on...

20. Do you do the following with your teeth?

21. Would you consider your lifestyle stressful?

22. Is your jaw pain/headaches aggravated by increased stress levels?

23. Have you ever been diagnosed with arthritis?

24. Do you have...

25. Do you notice...

26. Are you currently taking medications for this problem?

Which type?

Dental History

1. Have you had, or was there ever a time when you had...

When were your teeth straightened?

If past treatment on jaw joints, was treatment successful?

2. Have you had a splint/dental guard made in the last 24 months?

Is your dental guard for

3. If you would like to expand on any answer, please do so

Have questions for us?