Dr. Jennifer Silver - Cosmetic Dentistry - Making better SmilesFREE CONSULTATION

Pain Care Test

Please fill out this form on your TMJ/TMD Symptoms

Gender
MaleFemale

How did you find us?*
InternetReferral from Medical DoctorReferral from DentistFriend and/or Family MemberOther

Headaches
yesno

Headache frequency
1 to 5 per month6 to 10 per month10 to 15 per monthmore that 15 per monthNot applicable

How long do your headaches last
minuteshoursall daydaysnot applicable

Pain in Jaw Joints
leftrightnone

Pain in ear
leftrightnone

Pain behind eyes
leftrightnone

Pain in Upper Jaw
leftrightnone

Pain in Lower Jaw
leftrightnone

Pain in back of neck
leftrightnone

Pain in shoulder
leftrightnone

Pain in Forehead
leftrightnone

Pain in Temples
leftrightnone

Pain on side of face
leftrightnone

Grating sound in Jaw Joint
leftrightnone

Subjective hearing loss
leftrightnone

Ringing sound in ear
leftrightnone

Fullness, pressure, blockage in ear
leftrightnone

Clicking, snapping, popping sound in Jaw Joint
leftrightnone

Dizziness (vertigo)
yesno

Upset stomach, nausea
yesno

Difficulty chewing or swallowing
yesno

Do you snore
YesOccasionallyNo

Do you wake up gasping for air
YesOccasionallyNo

Do you sleep through the night
YesOccasionallyNo

Do you wake up rested
YesOccasionallyNo

Are you constantly tired
YesOccasionallyNo

Do you mouth breath at night
YesOccasionallyNo

How many years, months, weeks or days have you been bothered by these problems?
yearsmonthsweeksdays

Have you had injury to your jaw or face?
yesno

Are you considering or already in litigation with respect to these problems?
yesno

Dr. Jennifer Silver - Cosmetic Dentistry - Making better SmilesFREE CONSULTATION