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.
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) * 6. Pressing in my ears (E) * 7. Pressing the back of my neck (G) * 8. Pressing the sides of my neck (H) * Select the option that best describes how much of the time each statement below applies to you. 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 or closes 37. I think my bite is off 38. I have pain which gets worse with stress or tension 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 in 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 seems to be changing 55. A light touch on one side of my face causes shock-like pain on the other 56. I have 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 can open my mouth as wide as I used to 69. The way my back teeth fit 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 of things 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 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