Triangle Dental Temporomandibular Joint (TMJ) Questionnaire

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

First Name

Last Name

Occupation

Date Of Birth

Email Addressa valid email

Do you attend the dentist regularly for checkups and prevention?please tick

YesNo

Your History

Describe the problem(s) you have been experiencing? Please provide as much detail as possible.

0 /

What is your ideal solution/goal from potential treatment?

0 /

Trauma history

Have you ever had trauma to your head and neck? Eg. Whiplash, Sports Injury, Fall

0 /

Please tick whether you have had any of the following treatments:

Orthodontics / Braces / InvisalignResults

Good Fair Poor

Occlusal Adjustment / Bite AdjustmentResults

Good Fair Poor

TMJ PhysiotherapyResults

Good Fair Poor

TMJ Splint / NightguardResults

Good Fair Poor

TMJ Arthroscopic Surgery / Minor SurgeryResults

Good Fair Poor

TMJ Open Joint Surgery / Major SurgeryResults

Good Fair Poor

TMJ Prosthetic ReplacementResults

Good Fair Poor

Splint History

Please write about any nightguards/orthotic appliances you have tried

0 /

Were you able to wear the guard as prescribed?Results

Good Fair PoorN/A

Current and Past Medications for TMJ

Please indicate any medications you are on or you have tried for this condition

0 /

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:

Any Other Areas...more details

0 /

Does it hurt to move your jaw?

YesNo

Does it hurt to chew?

YesNo

Does the pain/problem limit your function?

YesNo

If Yes, how does the pain limit your function

0 /

When is the pain worse?

MorningAfternoonEvening

Other Time

0 /

Does anything you do make the pain worse?

YesNo

If yes, what makes it worse?

0 /

Does anything you do make the pain better?

YesNo

If yes, what makes it better?

0 /

What other healthcare professionals have you seen for this problem?

0 /

Are you aware of clicking or popping?

YesNo

When?

0 /

Does your jaw ever lock?

NoLocks in the open positionLocks in the closed position

How has this been treated?

0 /

Can you do anything to prevent or treat this?

0 /

Do you have hypermobile joints (ultra flexible)

YesNoSometimes

Aware of clenching/grinding?

YesNoSometimes

Awareness of your teeth when you wake up?

YesNoSometimes

Do you have trouble getting to sleep?

YesNoSometimes

Do you sleep well?

YesNoSometimes

Do you consider yourself to be under a lot of stress?

YesNoSometimes

In the last 5 years:

Has your bite changed?

YesNo

Are your teeth getting shorter or thinner?

YesNo

Impression:

What do you understand is the cause of your symptoms?

0 /

What are you expecting will help you?

0 /

What are you doing to cope with your symptoms?

0 /

How are other people responding to your symptoms?

0 /

Have you had time off work with symptoms?

0 /

Has your social life been restricted due to symptoms?

0 /

Life stress, mood, anxiety?

0 /

The pain is having this effect on my life:

Key

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

SnoringTirednessObserved you stop breathingBlood pressure

BANG QuestionairreTick any of the following if they apply to you

BMI over 35Age over 50Neck circumference over 40cm (over 15.7 inches)Gender Male

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?

e.g. bad taste, nausea, visualmore details

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Anything else you would like your dentist to know?

Commentsmore details

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