The first question should only be answered if you have upper and lower front teeth or are wearing a replacement for them.
0
1
2
3
4
1
Mark the number of fingers that fit.
For questions # 2 - 8 below, locate each area on your face (except F) using the lettered diagram. Press each area firmly on both sides of your face, holding it for 5 seconds. Mark the number that indicates the maximum amount of pain you feel.
0 = no pain
0
1
2
3
4
2
Pressing my temples (A on diagram)
3
Pressing my jaw joints (B on diagram)
4
Pressing my jaw muscles (C on diagram)
5
Pressing the muscles under the sides of my jaw (D on diagram)
6
Pressing in my ears (E on diagram)
7
Pressing the back of my neck (G on diagram)
8
Pressing the sides of my neck (H on diagram)
Mark the number which best describes how much of the time each statement below applies to you,
0 - none of the time1 - a little of the time2 - a moderate amount of time3 - quite a bit of time4 - all of the time
0
1
2
3
4
9
Just a light touch on my face causes shock-like pain.
10
My jaw must click or pop before I can open it wide.
11
My jaw opens all the way without any sideways movements.
12
My jaw locks open.
13
I have headaches which begin after seeing flashes of light or dark spots.
14
My jaw moves easily.
15
I have health problems which haven't responded to treatment.
16
I have pain in my jaw joint(s) (B on the diagram).
17
My jaw tires easily when chewing.
18
I have headaches which are made worse by bright light.
19
It hurts my teeth when I bite.
20
I have muscle or joint pain in areas other than my head or neck.
21
I can move my jaw more to one side than the other.
22
I feel tense and worried.
23
I have drainage from my ear(s).
24
I feel sad and depressed.
25
I clench my teeth.
26
My bite feels comfortable.
27
I have jaw pain which gets worse the more I move my jaw.
28
It is difficult to find a comfortable position for my jaw.
29
I have pain in my ear(s) (E on diagram).
30
I have sinus problems.
31
When I bite down normally, my front teeth touch.
32
During my life, I've had many different painful disorders.
33
I have facial pain which comes on suddenly like electric shocks.
34
I can open my mouth as far as possible without pain.
35
I have pain in or behind my eye(s).
36
My jaw makes a grating or grinding noise when it opens and closes.
37
I think my bite is off.
38
I have pain which gets worse with stress or tension.
Mark the number which best describes how much of the time each statement below applies to you,0 - none of the time1 - a little of the time2 -a moderate amount of time3 - quite a bit of time4 - all of the time
0
1
2
3
4
39
My jaw clicks or pops when I chew.
40
I can bite down hard without pain in my jaw.
41
One painful problem is followed by another.
42
I have jaw pain which makes me feel sick and feverish.
43
I grind my teeth during the day.
44
I have numb areas on my face.
45
I use nerve pills, sleeping pills, or alcohol for relief.
46
I can move my jaw smoothly.
47
I can chew without bumping my teeth unexpectedly.
48
I have a feeling of pins and needles on my face.
49
I have pain in my jaw muscles (C on diagram).
50
I have pain in the back of my neck (G on diagram).
51
Over the years, I've been under a lot of stress.
52
My jaw twitches or jerks uncontrollably.
53
When I bite down normally, my back teeth touch.
54
The way my front teeth fit together seems to be changing.
55
A light touch on one side of my face causes shock-like pain on the other.
56
I have a ringing in my ear(s).
57
I have pain which gets worse with certain people or situations.
58
I have pain in the side(s) of my neck (H on diagram).
59
I have a steady pain across my forehead.
60
I have many changing pains.
61
I feel angry.
62
Other people notice noise from my jaw when I chew.
63
I can chew food as well as I used to.
64
I have health problems which seem to be getting worse.
65
I have pain in the muscles under my jaw (D on diagram).
66
I have pain in my temple(s) (A on diagram).
67
I feel anxious.
68
I am able to open my mouth as wide as I used to.
Mark the number which best describes how much of the time each statement below applies to you, using the following key:
0 - none of the time1 - a little of the time2 - a moderate amount of time3 - quite a bit of time4 - all of the time
0
1
2
3
4
69
The way my back teeth fit together seems to be changing.
70
I sleep well.
71
I have head or facial pain which gets worse when I bend over.
72
When I touch one side of my face, the other side gets numb.
73
My jaw gets stuck and won't open all the way.
74
The only real problems in my life are problems with my physical health.
75
I've had conflicting doctors' opinions about health problems.
76
I can move my jaw in any direction without pain.
77
I have facial pain which gets worse in cold weather.
78
I feel frustrated.
79
I have a stuffy nose.
80
Recently I've been under a lot of stress.
81
I have headaches which make me feel sick to my stomach.
82
I can take big bites ofthings like apples.
83
I have work or family pressures.
84
I have pain and stiffness in my finger joints.
85
My back teeth feel like they fit together properly.
86
I believe I have an incurable problem in spite of reassurance by doctors.
87
In the morning my teeth are sore and my jaw is tired.
88
My ears feel blocked or stopped up.
89
I have many health problems.
90
My jaw moves just as far forward as it used to.
91
I have difficulty swallowing.
92
I have pain behind my ear(s) (F on diagram).
93
I have facial pain when other joints are also sore.
94
I have nervous problems.
95
I have throbbing headaches.
96
I feel dizzy.
97
I consider myself to be a sickly person.
Thank you for persevering. Your answers are very important in helping us arrive at your diagnosis. Be sure to complete additional forms that are required.
We enjoy answering your questions. 505-474-4644
Center For Dental Medicine • 2019 Galisteo St. • J2 • Santa Fe, NM 87505(Behind Los Alamos National Bank, St. Michael's & Galisteo) Map
