TMD form

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Patient Information

Name(Required)

First Last

Age(Required)

Occupation

Sex

Female

Male

Non-binary

Transgender

1. What areas of TMD concern you the most?

2a. How many days/weeks/months/years ago did this problem begin?

2b. At what age?

3a. Please indicate areas of pain by drawing on the figures below:

Comments

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3a. Please indicate areas of pain by drawing on the figures below:

3b. Please indicate areas of pain by drawing on the figures below:

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3b. Please indicate areas of pain by drawing on the figures below:

3c. Please indicate areas of pain by drawing on the figures below:

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3c. Please indicate areas of pain by drawing on the figures below:

4. From the time you begin experiencing pain, please indicate how long the pain lasts:

seconds

minutes

hours

days

Comments

5. Pain attack frequency (indicate continuous if there are no pain-free periods):

6. On a scale from 1 (no pain) to 10 (worst pain), please indicate the severity of your pain:

7. Please indicate factors that precipitate and/or aggravate your TMD pain:

8. Please indicate methods and/or medications you currently utilize to ease your TMD pain:

9. Please indicate how you would describe this pain (Check all that apply):

Pressing

Throbbing

Electric

Piercing

Burning

Sharp

Other

10. Please check all accompanying signs and symptoms:

Headache

Nausea

Photophobia

Vomiting

Dizziness

Tearing

Swelling

Rhinorrhea

Redness

11. Is there a history of trauma?

Yes

Indicate date(YY/MM/DD)

Please indicate a description of trauma

12. Has your condition interfered with any aspects of your life?

Yes

Please select all that apply

Work Activities

Family Activities

Chewing

Physical Activities

Social Activities

Swallowing

Emotions

Weight Gain

Sleep

Sexual Activities

Weight Loss

Other

13. Does the TMD pain wake you during sleep?

Yes

14. Please list other doctors or healthcare professionals you have seen for your current problem. Also indicate treatment(s) recommended.

PRACTITIONER

PROCEDURE

15. Have you ever had or currently have any of the following medical conditions? (Please check each one that applies)

Anxiety/Depression

Sleeping problems

Nervous disorders/Fainting spells

Headaches (tension)/(migrane)

Muscle tension

Cancer

Fibromyalgia

Parkinson’s/Huntington’s

Muscle tension/spasm

Irritable bowel syndrome

Constipation/Difficulty urinating

glaucoma

Other

Specify other

16. Do you have caffeine in your diet?

Coffee

Tea/Cola

Chocolate

Coffee – Cups per day:

Tea/ Cola – Servings per day:

Chocolate – Servings per day:

Please add any information that you feel would be valuable for your care, diagnosis, and treatment:

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