Download tmj dysfunction – symptom visual index

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TMJ DYSFUNCTION – SYMPTOM VISUAL INDEX
PATIENT DETAILS:
Date: _____ / _____ / _____
Headaches, Neck Pain, Ear and Jaw Pain are just some of the symptoms of TMJ Dysfunction.
Name:
If the jaws, teeth and jaw joint are not functioning correctly a wide range of symptoms result. Many patients search for years for the
cause of their chronic, persistent pain by doing such things as going from one doctor to another, or from Chiropractors to Physiotherapists etc., with little relief. If the cause of this pain is TMJ dysfunction many of the groups of symptoms below will be present.
Age: D.O.B:
Address:
The following questionnaire will help to decide if you have TMJ Dysfunction and if help can be provided with the TMJ treatment.
Zip Code:
Occupation:
Insurance:
Referred By:
Payment Method:
Indicate your 3 main complaints
(1)
H. Ear Pain, Ear Problems, and Loss of Balance:
1. Hissing, buzzing or ringing (tinnitus).
2. Diminished hearing (subjective hearing loss).
3. Ear Pain without infection (otalgia).
4. Clogged, stuffy, “itchy” ears, feeling of fullness
5. Balance problems, “vertigo” (disequilibrium).
A. Head Pain, Headache Problems, Facial Pain:
1. Forehead (frontal).
2. Temples (Temporal).
3. “Migraine” type headache.
4. “Cluster” headache.
5. Maxillary sinus headache (under the eyes).
6. Headaches at the back of the head.
(3)
When are the symptoms worse:
Triggered by:
G. Throat Problems:
1. Swallowing difficulties.
2. Tightness of throat.
3. Sore throat without infection.
4. Frequent coughing or constant
clearing of throat.
5. Feeling of foreign object in throat.
6. Tongue Pain.
C. Mouth, Face, Cheek, and Chin Problems:
1. Discomfort.
2. Limited opening.
3. Inability to open smoothly, evenly.
4. Jaw deviates to one side when opening.
5. Inability to “find bite”.
What health practitioners have you consulted:
Additional questions Do you breathe through your mouth: Y / N
Do you snore at night: Y / N
Are you tired during the day: Y / N
Do you clench and grind your teeth: Y / N
Other complaints that may be relevant:
A B C D E F G H
B. Eye Pain and Eye Orbital Problems:
1. Eye (orbital) pain; above, below, behind.
2. Bloodshot eyes (hyperemia).
3. Blurring of vision.
4. Bulging appearance.
5. Pressure behind the eyes
6. Light sensitivity (Photo – phobia)
7. Watering of the eyes.
(2)
When did these symptoms first become
apparent:
Circle most severe symptoms group
F. Neck and Shoulder Problems:
1. Lack of mobility – reduced range of
movement.
2. Neck Pain and/or Stiffness.
3. Tired, sore, neck muscles.
4. Shoulder aches.
5. Back pain upper and lower
6. Arm and finger tingling, numbness
and or pain.
D. Teeth and Gum Problems:
1. Clenching, grinding at night (bruxism).
2. Looseness and or soreness of back teeth.
3. Tooth pain (toothache).
E. Jaw and Jaw Joint (TMJ) Problems:
1. Clicking, popping jaw joints.
2. Grating sounds (crepitus).
3. Jaw locking opened or closed.
4. Pain in cheek muscles.
5. Uncontrollable jaw, tongue movements.
TMJ MUSCLE AND JOINT PALPATION
OFFICE USE ONLY
Tender to Palpation
R
Temporomandibular Joint Examination
L
Palpation through External auditory meatus
Temporalis
TMJ’s
Lateral Pterygoid
R
L
Pain
Medial Pterygoid
Clicking
Opening
Masseter
Closing
Sternocleidomastoid
TMJ Range of Motion
Posterior Cervicals
Trapezius
Posture
Forward Head Posture
Opening
Lateral
Protrusive
(>40mm Normal)
(>10mm Normal)
(>10mm Normal)
Shoulders - Low
Test with TMJ Appliance in place
Less Pain
No Change
R
Cervical Range of Motion
Rotation
Diagnostic Impression:
R
Extension
B
L
F
L
Temporalis
Lateral Pterygoid
Follow up appointment after
Medial Pterygoid
TMJ Appliance
Masseter
Build ups
Sternocleidomastoid
Posterior Cervicals
Less Pain
Treatment Plan:
Splint. Type.
R
No Change
L
Temporalis
Lateral Pterygoid
Adjunctive Treatment
Medial Pterygoid
Stage II
Masseter
Comments
Sternocleidomastoid
Trapezius
Posterior Cervicals
Posture
Trapezius
Forward Head Posture
Shoulders - Low
Posture
Date
Forward Head Posture
Shoulders - Low
Weeks (4 to 6 weeks)