TMJ Disorder Questionnaire TMJ Disorder Questionnaire Name*FirstLastEmail*Enter EmailConfirm EmailPhone*Please contact me to discuss my responses by:*PhoneEmailAt appointment (only select if appt is scheduled)Best time to contact me:*MorningAfternoonEveningDo you suffer from migraines or other headaches? How severe are they?*NoneMildModerateSevereIf you get headaches, when do they tend to occur?While sleeping or waking upMorningsMid-days or afternoonsEveningsDuring or after chewing/eatingFollowing an auraCheck all symptoms that you are experiencing:*Facial painJaw pain at restJaw pain during or after chewingDifficulty chewingDifficulty or discomfort while opening mouthJaw joint clicking, popping, locking, or crackingNeck pain or stiffnessBack pain or stiffnessTeeth clenching or grindingTeeth painEar ringingEar pressure or congestionDizzinessEar painTinging in hands or fingersNone of the aboveCheck all sleep disorder symptoms that you are experiencing (if any):*SnoringFatigue during the dayWaking up during the nightWeight gain or weight lossLoss of libidoHave tried CPAPNone of the aboveDo you have any other symptoms you'd like to list here?How long have you been experiencing your symptoms?*Which symptoms are the most troubling to you (the ones you'd most like to address)?*How did you hear about us?*Medical Doctor referred meDentist referred meFriend or Family Member referred meInternet searchtmjcleveland.comPhonebookOtherAnything else you would like to discuss? Questions? We will be sure to address it when we follow up:EmailThis field is for validation purposes and should be left unchanged.