Temporomandibular Disorder History Form

Please complete this form. When you are finished, please press on the SEND button and your form will be submitted to us. Thank you.

If you have any questions, please contact our office at 780-435-3641.  If you prefer you can fax the form to us at 780-436-4354 or bring in a printed copy with you to your appointment.

Your answers to the following questions will be helpful in selecting the safest and most effective means of providing your orthodontic care. All information will be kept confidential.

Symptoms

Please check each symptom that applies.

Jaw Joint Problems Left Right Comments
Joint clicking or popping
Grating noises
Jaw locks open
Jaw locks closed
Limited jaw opening
Jaw does not open smoothly
Soreness of jaw joints
Soreness of face muscles
Teeth Problems Left Right Comments
Teeth grinding
Teeth clenching
Soreness of one or more teeth
Looseness of one or more teeth
Head and Facial Pain Left Right (0=least) Degree of Pain (10=most)
Migraine-type headache
Cluster headaches
Sinus headaches
Headaches in back of head
Hair and/or scalp painful to touch
Ear or Balance Problems Comments
Pain in ear
Ringing or buzzing in ears
Clogged or stuffy ears
Diminished hearing
Dizziness or vertigo
Poor sense of balance
Throat Problems Comments
Swallowing difficulty
Throat tightness
Throat soreness
Laryngitis
Voice fluctuations
Throat congestion
Frequent cough
Frequent throat clearing
Excessive salivation
Tongue pain
Pain in roof of mouth
Neck and/or Shoulder Problems Comments
Neck/shoulder/back pain
Neck/shoulder/back reduced mobility
Frequent neck muscle fatigue
Arm or finger tingling, numbness, pain
Eye Problems Comments
Pain around or behind eyes
Bloodshot eyes
Blurred vision
Pressure behind eyes
Light sensitivity
Watering of eyes
Drooping of eyelids
Patient Health Information