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TMJ MRI QUESTIONNAIRE

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PATIENTS NAME:

Date:

The following questions will help us provide more useful results to your referring clinician.  Please check either 'Yes' or 'N' for each of the following questions.  If the answer is 'Yes' to any of the following, please indicate if symptoms are on the left, right, or both sides.
Thank you very much for your cooperation.
 

1.

 How long have you had these symptoms?

2.

Is it difficult or painful to open your mouth (e.g., yawning), chew or talk?

 Yes No
 

If yes, please explain:

3. 

Does your jaw "get stuck", "lock", or "go out"?

 Yes No
 

If yes, please explain:

4. 

Does your jaw make noise when moving (e.g. click, pop or grind)?

 Yes No
 

If yes, please explain:
5.

Are headaches, neckaches, facial pain or toothaches frequent?

 Yes No
 

If yes, please explain:
6.

Has there been a recent injury to the head, neck or jaw?

 Yes No

If yes, please explain:
7.

Have you had any treatment (including surgery) for any facial pain or a jaw problem?

 Yes No
 

If yes, what treatment did you receive?
         
  If you are having pain, please indicate where you are having it with an 'X' on the diagram below:
 

 
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