Your Information Name*
First Name *
Last Name *
1. What is/are your main complaint(s):Main Complaint 1 Main Complaint 2 Main Complaint 3
2. What date did your problem start?
3. Did anything trigger/precipitate your pain? Did anything trigger/precipitate your pain?
4. Which side is worse? Which side is worse?
5. Would you call it...Would you call it...
6. Is the pain...Is the pain...
7. Worst Jaw Pain Today
Worst Jaw Pain Today (Past 12 Months)
8. Can you locate a specific site of pain? Can you locate a specific site of pain?
9. Has the severity of pain been... Has the severity of pain been...
10. Is the pain modified by jaw movement, function, or parafunction (chewing, opening, talking, clenching)? Is the pain modified by jaw movement, function, or parafunction (chewing, opening, talking, clenching)?
11. Do you hear...Do you hear... 1 Do you hear... 2
12. Did your joints have sounds in the past that have now stopped?Did your joints have sounds in the past that have now stopped?
13. Do you have difficulty opening your mouth? Do you have difficulty opening your mouth?
14. Has the jaw ever locked or caught so that you could not fully open your mouth? Has the jaw ever locked or caught so that you could not fully open your mouth?
15. Are your jaws tired after eating a meal? Are your jaws tired after eating a meal?
16. Have you modified your diet as a result of the jaw pain?Have you modified your diet as a result of the jaw pain?
17. Do you have headaches? Do you have headaches?
Are the headaches felt in your temples?
Are the headaches worsened by jaw function (chewing, talking clenching)
18. Is the condition worse...Is the condition worse...
19. Do you do the following with your teeth?Do you do the following with your teeth?
20. Would you consider your lifestyle stressful?Would you consider your lifestyle stressful?
21. Is your jaw pain/headaches aggravated by increased stress levels?Is your jaw pain/headaches aggravated by increased stress levels?
22. Have you ever been diagnosed with arthritis? Have you ever been diagnosed with arthritis?
23. Do you have neck pain?Do you have neck pain?
24. Does your neck pain aggravate your jaw pain?Does your neck pain aggravate your jaw pain?
25. Do you notice... Do you notice...
26. Are you currently taking medications for this problem? Are you currently taking medications for this problem?
27. Medications for jaw pain?Medications for jaw pain?
Psychological Symptoms
28. During the past 2 weeks, how often have you experienced the following?Nervous, anxious, or on edge Unable to stop or control worrying Feeling down, depressed, or hopeless Little interest or pleasure in activities
29. Has anyone ever told you that you stop breathing during your sleep, or do you ever wake up gasping or choking for air? Has anyone ever told you that you stop breathing during your sleep, or do you ever wake up gasping or choking for air?
30. Do you often feel excessively tired or sleepy during the day, even after what seems like a full night’s sleep? Do you often feel excessively tired or sleepy during the day, even after what seems like a full night’s sleep?
If you answered “Yes” to one of the questions above, a formal sleep study may be recommended.
Dental History
Have you had, or was there ever a time when you had...
If teeth were straightened, when?
Have you pursued physical therapy/massage/acupuncture/chiropractic for your jaw pain?Have you pursued physical therapy/massage/acupuncture/chiropractic for your jaw pain?
If past treatment on jaw joints, was treatment successful?If past treatment on jaw joints, was treatment successful? Have you had a nightguard/dental appliance made in the last 24 months?
Do you warm your nightguard up in how water before using it? Do you warm your nightguard up in how water before using it?
Have you had your nightguard adjusted by your dentist to ensure optimal fit and function? Have you had your nightguard adjusted by your dentist to ensure optimal fit and function?
Is your dental guard for
If you would like to expand on any answer, please do soIf you would like to expand on any answer, please do so
