TMJ evaluation

During your comprehensive evaluation at OcciDental of Brooklyn, please be ready to answer the following questions.

To schedule an appointment:

Please call us at
(718)568-0242


1. Do you have popping, clicking, or grating noises in your right jaw joint?....................................... left jaw joint?..........................................

Yes No
2. When did you first notice the noise?_______________________________________________________ 

3. Has the noise recently become more pronounced? .................................................................

When? ________________________________________________________________________ 

4. Do you have pain in or around the right joint? .....................................................................

left joint? ......................................................................... 

5. When did you first notice the pain? _______________________________________________________ 

6. Has the pain recently become more pronounced? ..................................................................

When? ________________________________________________________________________

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7. Is the pain worse: A.M. ______________ P .M. ______________ 8. Is the pain: Dull ______________ Stabbing ______________ Throbbing ____________

At meals
V ariable Continuous Intermittent Other

_______________
_______________                                                                                                                 

_______________ _______________ _______________

9. Does the pain sometimes feel like it is in your ear? ............................................................... 

10. Do you think this problem has affected your hearing? ........................................................... 

11. Does your jaw problem interfere with your normal daily activities? .......................................... 

12. Does your jaw problem interfere with sleeping? ................................................................. 

13. Are you taking or have you taken any medication(s) for this problem? .......................................

Explain _______________________________________________________________________ 

14. Do you have frequent headaches or neckaches? .................................................................. 

15. Have you ever had a severe blow or trauma to the head, neck, or jaw? .......................................

Which area? ________________________________ When? ________________________ Explain _______________________________________________________________________

_______________________________________________________________________ 

16. If yes, are you currently involved in litigation related to the event? ........................................... 1

7. Did anything else occur which might be related to the onset of the problem? ................................

Explain _______________________________________________________________________ _______________________________________________________________________

Yes No Pain in teeth _________ Missing teeth _________ Other ________

18. Do you have difficulty chewing? .................................................................................... Because of: Pain in joint _________ Limited opening _________ Clicking ________

  1. a. What makes the pain worse? ___________________________________________________________ b. What makes the pain better? ___________________________________________________________

  2. Has your mouth ever locked open so that you were unable to close it? ........................................ Explain ________________________________________________________________________ ________________________________________________________________________

  3. Do you or have you had problems opening your mouth wide? .................................................. Explain ________________________________________________________________________

                  ________________________________________________________________________
    
  4. Please indicate the time sequence in which you became aware of the following problems 1st, 2nd, 3rd, etc.

    Number only those problems which apply to you.
    Pain _____ Noise _____ Limited opening _____ Locking _____ Other _____

  5. Which aspects of your problem concern you the most? What is your chief complaint? ______________ ___________________________________________________________________________________ ___________________________________________________________________________________

  6. Are you aware of clenching your teeth? ............................................................................

  7. Do you grind your teeth? ............................................................................................. When? _______________________________________________________________________

  8. Has there been a recent change in your lifestyle such as a change in marital status, childbirth, change of employment, death in immediate family, or other stressful events?............................................

    Explain _______________________________________________________________________ _______________________________________________________________________

  9. Do you think nervous tension seems to affect this problem? .................................................... Explain _______________________________________________________________________

                  _______________________________________________________________________
    
  10. Have you had this problem with other joints, or have you been diagnosed with arthritis? .................. Explain _______________________________________________________________________

  11. Have you ever had orthodontic treatment? .........................................................................

    When? ______________________ Where? ________________________

  12. Have you had recent dental treatment?

    When? ______________________ Where? ________________________
    Explain _______________________________________________________________________

               ______________________________________________________
    
  13. Have you received previous treatment for this problem? ........................................................ Explain _______________________________________________________________________ _______________________________________________________________________

  14. Do you wish to add to the above information? .................................................................... __________________________________________________________________________________

      _______________________________________________________________