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

TMJ Pain Questionnaire

 

Step 1 of 2

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  • Date Format: MM slash DD slash YYYY
  • INSURANCE INFORMATION (MUST BE COMPLETED BEFORE EXAMINATION DATE)

  • Date Format: MM slash DD slash YYYY
  • Medical Insurance

  • If your condition / pain is due to a motor vehicle accident, please complete this section:

    Motor Vehicle Insurance (registered owner of vehicle’s insurance)
  • Legal

  • We do not accept workers compensation claims.

    Symptoms ( Please Check Any/All Symptoms that you have Experienced)
  • Please indicate the location of your pain on the following diagrams. If your pain starts in one area but radiates to others, please indicate by writing it below with descriptions.

  • Please list the 4 most important symptoms you wish to resolve them from the list

  • For each of the pains you have outlined, please indicate the words you feel best describe your pain.

  • Severity

  • Frequency

  • Duration

  • CAUSE OF CHIEF CONCERN

    The initial cause of my problem was: (Ctrl + click to select multiple choice)
Dr. Jennifer Silver - Cosmetic Dentistry - Making better SmilesFREE CONSULTATION