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TMJ Scale

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 TMJ Scale

  • TMJ Scale

  • This questionnaire is designed to help your doctor evaluate your problem. Please answer all questions as honestly as possible. Do not skip any questions even if you are not absolutely sure.
  • Date Format: MM slash DD slash YYYY
  • 1. This question should only be answered if you have upper and lower front teeth or are wearing a replacement for them. Open your mouth as wide as possible and position your hand as shown in the diagram below. Place as many fingers as possible between your upper and lower front teeth. Now select the option below indicating the number of fingers.

  • For questions 2-8 below, locate each area on your face using the lettered diagram. Press each area firmly on both sides of your face. Select the option that indicates the maximum amount of pain you feel.
  • Select the option that best describes how much of the time each statement below applies to you.
After submitting, feel free to return to the Patient Forms page. Please note, there are multiple forms for each section.

Schedule Your Appointment with the Holistic Dentist

Every service we offer is aimed at improving your overall health. We offer several procedures that eliminate the need for surgical incisions, reducing your discomfort, downtime, and the need for multiple visits. Call our office to schedule your consultation today.