HISTORY FORM FOR PATIENT WITH
TEMPOROMANDIBULAR DISORDER
 
 
Date:  Date of Birth: 
Name:           
Address: 
City:       State/Province:       Zip/Postal Code: 
Referred by: 
 
MAJOR REASON FOR CURRENT EVALUATION
1)     Describe what you think the problem is: 
2)     What do you think caused this problem? 
3)     Describe, in order (first to last), what you expect from your treatment?
        
 
GENERAL HISTORY:
1)     Are you presently under the care of a physician or have you been in the past year?   
        Physician's Name: 
        Treatment: 
        Name of medication(s) you are currently taking: 
2)     How would you describe your overall physical health? (0 = Poor, 5 = Average, 10 = Excellent) 
3)     How would you describe your dental health? (0 = Poor, 5 = Average, 10 = Excellent) 
        Dentist Name:  Date of last appointment: 
4)     Have you ever had any major dental treatment in the last two years? 
        If yes, please check procedure(s):       
        Date(s) of Third Molar (wisdom tooth) extraction(s) 
 
FACIAL INJURY/TRAUMA HISTORY: 
1)     Is there any childhood history of falls, accidents or injury to the face or head? 
       
2)     Is there any recent history of trauma to the head of face? (Auto accident, sports injury, facial impact)
       
3)     Is there any activity which holds the head or jaw in an imbalanced position? (Phone, swimming, instrument)
       
 
TMD TREATMENT HISTORY:
1)     Have you ever been examined for a TMD problem before? 
        If yes, by whom?  When? 
2)     What was the nature of the problem?     (Pain, noise, limitation of movement)
       
3)     What was the duration of the problem?  Months    Years    Is this a new problem? 
4)     Is the problem getting better, worse or staying the same? 
5)     Have you ever had physical therapy for TMD?
        If yes, by whom?  When? 
6)     Have you ever received treatment for jaw problems? 
        If yes, by whom?  When? 
        What was the treatment? (Please check below) 
       
        Other (Please explain) 
 
CURRENT MEDICATIONS/APPLIANCES
1)     Degree of current TMD pain: (0 = No pain, 5 = Moderate pain, 10 = Severe pain)  
2)     Frequency of TMD pain?       
3)     Is there a pattern related to pain occurrence?           
4)     Are you taking any medication for the TMD problem? If so, what type? 
5)     Are you aware of anything that makes your pain worse?    If yes, what? 
6)     Does your jaw make noise? 
        RIGHT        Other 
        LEFT          Other 
7)     Does your jaw ever lock open?     When did this first happen? 
8)     Has your jaw ever locked closed or partially closed? 
        When did this first occur? 
9)     Have any dental appliances been prescribed?   
        If yes, by whom? 
        Describe: 
10)    Are these appliances effective? 
11)    Is there any additional information that can help us in this area?
CURRENT STRESS FACTORS: (Please check each factor that applies to you) 
HABIT HISTORY: 
1)     Do you clench your teeth together under stress? 
2)     Do you grind/clench your teeth at night? 
3)     Do you sleep with an unsual head position?   
4)     Are you aware of any habits or activities that may aggravate         this condition? 
        Describe: 
SYMPTOMS: (Check each symptoms that applies) 
A.   HEAD PAIN, HEADACHES, FACIAL PAIN 
B.   EYE PAIN OR ORBITAL PROBLEMS 
 
C.     MOUTH, FACE, CHEEK, AND CHIN         PROBLEMS 
D.    TEETH AND GUM PROBLEMS 
 
E.    JAW & JOINT (TMD) PROBLEMS 
 
F.    PAIN, EAR PROBLEMS, POSTURAL        IMBALANCES 
G.    OTHER PAIN 
      
H.   THROAT PROBLEMS 
 
I.    NECK AND SHOULDER PAIN 
Using the figures below, select where you experience pain and use the boxes to describe where it is most severe.