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Triangle TMJ History Form
Please fill in the form below prior to your appointment and press the submit button once you have finished.
Patient Details
Do you attend the dentist regularly for checkups and prevention?please tick
Your History
What is your ideal solution/goal from potential treatment?
Trauma history
Do you or have you ever suffered from the following?please tick
Please tick whether you have had any of the following treatments:
Orthodontics / Braces / InvisalignResults
Occlusal Adjustment / Bite AdjustmentResults
TMJ PhysiotherapyResults
TMJ Splint / NightguardResults
TMJ Arthroscopic Surgery / Minor SurgeryResults
TMJ Open Joint Surgery / Major SurgeryResults
TMJ Prosthetic ReplacementResults
Splint History
Were you able to wear the guard as prescribed?Results
Current and Past Medications for TMJ
Indicate on the following scale how severe your pain is the majority of the time
Please indicate where you are having pain on the diagrams below:
Right Sided Pain / Problems
Left Sided Pain / Problems
Does it hurt to move your jaw?
Does it hurt to chew?
Does the pain/problem limit your function?
When is the pain worse?
Does anything you do make the pain worse?
Does anything you do make the pain better?
What other healthcare professionals have you seen for this problem?
Are you aware of clicking or popping?
Does your jaw ever lock?
Do you have hypermobile joints (ultra flexible)
Aware of clenching/grinding?
Awareness of your teeth when you wake up?
Do you have trouble getting to sleep?
Do you sleep well?
Do you consider yourself to be under a lot of stress?
Do you suffer from Headaches?
In the last 5 years:
Has your bite changed?
Are your teeth getting shorter or thinner?
What are you expecting will help you?
What are you doing to cope with your symptoms?
How are other people responding to your symptoms?
Have you had time off work with symptoms?
Has your social life been restricted due to symptoms?
Life stress, mood, anxiety?
The pain is having this effect on my life:


0      No Effect

1-3   Slight Effect (I can work / play but I am aware of pain

4-5   Moderate Effect (Some days I cannot function)

6-8   Severe Effect (Most days cannot function)

9-10 Cannot function at all

STOP QuestionairreTick any of the following if they apply to you
BANG QuestionairreTick any of the following if they apply to you

The BMI calculation divides weight in kilograms by height in metres squared. Use the BMI healthy weight calculator (opens in a new window) to check yours now.

If you answered yes to 3 or more items, you are at increased risk of Obstructive Sleep Apnoea. 

Your dentist will discuss this with you.

Any other symptoms?
Anything else you would like your dentist to know?
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