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FILL OUT THIS SIDE ONLY 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)