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.
Full Name*
First Name Last Name
Age*
Last 6 Numbers of SSN*
Today's Date
MM slash DD slash YYYY
Gender
- Male
- Female
Marital Status
- Single
- Married
- Separated
- Divorced
- Widowed
- Remarried
Ethnic/Racial Group
- Black
- Hispanic
- Oriental
- White
- Other
Number of School Years
Problem Length
- None
- 0-1 Month
- 1-5 Months
- 6-11 Months
- 1-2 Years
- 3-5 Years
- 6-10 Years
- 10+ Years
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.
*
- Less than 1 finger
- At least 1 finger
- At least 2 fingers
- At least 3 fingers
- At least 4 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.
2. Pressing my temples (A on diagram)*
- No pain
- Slight pain
- Moderate pain
- Quite a bit of pain
- Extreme pain
3. Pressing my jaw joints (B on diagram)*
- No pain
- Slight pain
- Moderate pain
- Quite a bit of pain
- Extreme pain
4. Pressing my jaw muscles (C on diagram)*
- No pain
- Slight pain
- Moderate pain
- Quite a bit of pain
- Extreme pain
5. Pressing the muscles under the sides of my jaw (D)*
- No pain
- Slight pain
- Moderate pain
- Quite a bit of pain
- Extreme pain
6. Pressing in my ears (E)*
- No pain
- Slight pain
- Moderate pain
- Quite a bit of pain
- Extreme pain
7. Pressing the back of my neck (G)*
- No pain
- Slight pain
- Moderate pain
- Quite a bit of pain
- Extreme pain
8. Pressing the sides of my neck (H)*
- No pain
- Slight pain
- Moderate pain
- Quite a bit of pain
- Extreme pain
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
- None of the time
- A little of the time
- A moderate amount of time
- Quite a bit of the time
- All of the time
10. My jaw must click or pop before I can open it wide
- None of the time
- A little of the time
- A moderate amount of time
- Quite a bit of the time
- All of the time
11. My jaw opens all the way without any sideways movements
- None of the time
- A little of the time
- A moderate amount of time
- Quite a bit of the time
- All of the time
12. My jaw locks open
- None of the time
- A little of the time
- A moderate amount of time
- Quite a bit of the time
- All of the time
13. I have headaches which begin after seeing flashes of light or dark spots
- None of the time
- A little of the time
- A moderate amount of time
- Quite a bit of the time
- All of the time
14. My jaw moves easily
- None of the time
- A little of the time
- A moderate amount of time
- Quite a bit of the time
- All of the time
15. I have health problems which haven't responded to treatment
- None of the time
- A little of the time
- A moderate amount of time
- Quite a bit of the time
- All of the time
16. I have pain in my jaw joint(s) (B on the diagram)
- None of the time
- A little of the time
- A moderate amount of time
- Quite a bit of the time
- All of the time
17. My jaw tires easily when chewing
- None of the time
- A little of the time
- A moderate amount of time
- Quite a bit of the time
- All of the time
18. I have headaches which are made worse by bright light
- None of the time
- A little of the time
- A moderate amount of time
- Quite a bit of the time
- All of the time
19. It hurts my teeth when I bite
- None of the time
- A little of the time
- A moderate amount of time
- Quite a bit of the time
- All of the time
20. I have muscle or joint pain in areas other than my head or neck
- None of the time
- A little of the time
- A moderate amount of time
- Quite a bit of the time
- All of the time
21. I can move my jaw more to one side than the other
- None of the time
- A little of the time
- A moderate amount of time
- Quite a bit of the time
- All of the time
22. I feel tense and worried
- None of the time
- A little of the time
- A moderate amount of time
- Quite a bit of the time
- All of the time
23. I have drainage from my ear(s)
- None of the time
- A little of the time
- A moderate amount of time
- Quite a bit of the time
- All of the time
24. I feel sad and depressed
- None of the time
- A little of the time
- A moderate amount of time
- Quite a bit of the time
- All of the time
25. I clench my teeth
- None of the time
- A little of the time
- A moderate amount of time
- Quite a bit of the time
- All of the time
26. My bite feels comfortable
- None of the time
- A little of the time
- A moderate amount of time
- Quite a bit of the time
- All of the time
27. I have jaw pain which gets worse the more I move my jaw
- None of the time
- A little of the time
- A moderate amount of time
- Quite a bit of the time
- All of the time
28. It is difficult to find a comfortable position for my jaw
- None of the time
- A little of the time
- A moderate amount of time
- Quite a bit of the time
- All of the time
29. I have pain in my ear(s) (E on diagram)
- None of the time
- A little of the time
- A moderate amount of time
- Quite a bit of the time
- All of the time
30. I have sinus problems
- None of the time
- A little of the time
- A moderate amount of time
- Quite a bit of the time
- All of the time
31. When I bite down normally, my front teeth touch
- None of the time
- A little of the time
- A moderate amount of time
- Quite a bit of the time
- All of the time
32. During my life, I've had many different painful disorders
- None of the time
- A little of the time
- A moderate amount of time
- Quite a bit of the time
- All of the time
33. I have facial pain which comes on suddenly like electric shocks
- None of the time
- A little of the time
- A moderate amount of time
- Quite a bit of the time
- All of the time
34. I can open my mouth as far as possible without pain
- None of the time
- A little of the time
- A moderate amount of time
- Quite a bit of the time
- All of the time
35. I have pain in or behind my eye(s)
- None of the time
- A little of the time
- A moderate amount of time
- Quite a bit of the time
- All of the time
36. My jaw makes a grating or grinding noise when it opens or closes
- None of the time
- A little of the time
- A moderate amount of time
- Quite a bit of the time
- All of the time
37. I think my bite is off
- None of the time
- A little of the time
- A moderate amount of time
- Quite a bit of the time
- All of the time
38. I have pain which gets worse with stress or tension
- None of the time
- A little of the time
- A moderate amount of time
- Quite a bit of the time
- All of the time
39. My jaw clicks or pops when I chew
- None of the time
- A little of the time
- A moderate amount of time
- Quite a bit of the time
- All of the time
40. I can bite down hard without pain in my jaw
- None of the time
- A little of the time
- A moderate amount of time
- Quite a bit of the time
- All of the time
41. One painful problem is followed by another
- None of the time
- A little of the time
- A moderate amount of time
- Quite a bit of the time
- All of the time
42. I have jaw pain which makes me feel sick and feverish
- None of the time
- A little of the time
- A moderate amount of time
- Quite a bit of the time
- All of the time
43. I grind my teeth during the day
- None of the time
- A little of the time
- A moderate amount of time
- Quite a bit of the time
- All of the time
44. I have numb areas on my face
- None of the time
- A little of the time
- A moderate amount of time
- Quite a bit of the time
- All of the time
45. I use nerve pills, sleeping pills, or alcohol for relief
- None of the time
- A little of the time
- A moderate amount of time
- Quite a bit of the time
- All of the time
46. I can move my jaw smoothly
- None of the time
- A little of the time
- A moderate amount of time
- Quite a bit of the time
- All of the time
47. I can chew without bumping my teeth unexpectedly
- None of the time
- A little of the time
- A moderate amount of time
- Quite a bit of the time
- All of the time
48. I have a feeling of pins and needles in my face
- None of the time
- A little of the time
- A moderate amount of time
- Quite a bit of the time
- All of the time
49. I have pain in my jaw muscles (C on diagram)
- None of the time
- A little of the time
- A moderate amount of time
- Quite a bit of the time
- All of the time
50. I have pain in the back of my neck (G on diagram)
- None of the time
- A little of the time
- A moderate amount of time
- Quite a bit of the time
- All of the time
51. Over the years, I've been under a lot of stress
- None of the time
- A little of the time
- A moderate amount of time
- Quite a bit of the time
- All of the time
52. My jaw twitches or jerks uncontrollably
- None of the time
- A little of the time
- A moderate amount of time
- Quite a bit of the time
- All of the time
53. When I bite down normally, my back teeth touch
- None of the time
- A little of the time
- A moderate amount of time
- Quite a bit of the time
- All of the time
54. The way my front teeth fit seems to be changing
- None of the time
- A little of the time
- A moderate amount of time
- Quite a bit of the time
- All of the time
55. A light touch on one side of my face causes shock-like pain on the other
- None of the time
- A little of the time
- A moderate amount of time
- Quite a bit of the time
- All of the time
56. I have ringing in my ear(s)
- None of the time
- A little of the time
- A moderate amount of time
- Quite a bit of the time
- All of the time
57. I have pain which gets worse with certain people or situations
- None of the time
- A little of the time
- A moderate amount of time
- Quite a bit of the time
- All of the time
58. I have pain in the side(s) of my neck (H on diagram)
- None of the time
- A little of the time
- A moderate amount of time
- Quite a bit of the time
- All of the time
59. I have a steady pain across my forehead
- None of the time
- A little of the time
- A moderate amount of time
- Quite a bit of the time
- All of the time
60. I have many changing pains
- None of the time
- A little of the time
- A moderate amount of time
- Quite a bit of the time
- All of the time
61. I feel angry
- None of the time
- A little of the time
- A moderate amount of time
- Quite a bit of the time
- All of the time
62. Other people notice noise from my jaw when I chew
- None of the time
- A little of the time
- A moderate amount of time
- Quite a bit of the time
- All of the time
63. I can chew food as well as I used to
- None of the time
- A little of the time
- A moderate amount of time
- Quite a bit of the time
- All of the time
64. I have health problems which seem to be getting worse
- None of the time
- A little of the time
- A moderate amount of time
- Quite a bit of the time
- All of the time
65. I have pain in the muscles under my jaw (D on diagram)
- None of the time
- A little of the time
- A moderate amount of time
- Quite a bit of the time
- All of the time
66. I have pain in my temple(s) (A on diagram)
- None of the time
- A little of the time
- A moderate amount of time
- Quite a bit of the time
- All of the time
67. I feel anxious
- None of the time
- A little of the time
- A moderate amount of time
- Quite a bit of the time
- All of the time
68. I can open my mouth as wide as I used to
- None of the time
- A little of the time
- A moderate amount of time
- Quite a bit of the time
- All of the time
69. The way my back teeth fit seems to be changing
- None of the time
- A little of the time
- A moderate amount of time
- Quite a bit of the time
- All of the time
70. I sleep well
- None of the time
- A little of the time
- A moderate amount of time
- Quite a bit of the time
- All of the time
71. I have head or facial pain which gets worse when I bend over
- None of the time
- A little of the time
- A moderate amount of time
- Quite a bit of the time
- All of the time
72. When I touch one side of my face, the other side gets numb
- None of the time
- A little of the time
- A moderate amount of time
- Quite a bit of the time
- All of the time
73. My jaw gets stuck and won't open all the way
- None of the time
- A little of the time
- A moderate amount of time
- Quite a bit of the time
- All of the time
74. The only real problems in my life are problems with my physical health
- None of the time
- A little of the time
- A moderate amount of time
- Quite a bit of the time
- All of the time
75. I've had conflicting doctors' opinions about health problems
- None of the time
- A little of the time
- A moderate amount of time
- Quite a bit of the time
- All of the time
76. I can move my jaw in any direction without pain
- None of the time
- A little of the time
- A moderate amount of time
- Quite a bit of the time
- All of the time
77. I have facial pain which gets worse in cold weather
- None of the time
- A little of the time
- A moderate amount of time
- Quite a bit of the time
- All of the time
78. I feel frustrated
- None of the time
- A little of the time
- A moderate amount of time
- Quite a bit of the time
- All of the time
79. I have a stuffy nose
- None of the time
- A little of the time
- A moderate amount of time
- Quite a bit of the time
- All of the time
80. Recently I've been under a lot of stress
- None of the time
- A little of the time
- A moderate amount of time
- Quite a bit of the time
- All of the time
81. I have headaches which make me feel sick to my stomach
- None of the time
- A little of the time
- A moderate amount of time
- Quite a bit of the time
- All of the time
82. I can take big bites of things like apples
- None of the time
- A little of the time
- A moderate amount of time
- Quite a bit of the time
- All of the time
83. I have work or family pressures
- None of the time
- A little of the time
- A moderate amount of time
- Quite a bit of the time
- All of the time
84. I have pain and stiffness in my finger joints
- None of the time
- A little of the time
- A moderate amount of time
- Quite a bit of the time
- All of the time
85. My back teeth feel like they fit properly
- None of the time
- A little of the time
- A moderate amount of time
- Quite a bit of the time
- All of the time
86. I believe I have an incurable problem in spite of reassurance by doctors
- None of the time
- A little of the time
- A moderate amount of time
- Quite a bit of the time
- All of the time
87. In the morning my teeth are sore and my jaw is tired
- None of the time
- A little of the time
- A moderate amount of time
- Quite a bit of the time
- All of the time
88. My ears feel blocked or stopped up
- None of the time
- A little of the time
- A moderate amount of time
- Quite a bit of the time
- All of the time
89. I have many health problems
- None of the time
- A little of the time
- A moderate amount of time
- Quite a bit of the time
- All of the time
90. My jaw moves just as far forward as it used to
- None of the time
- A little of the time
- A moderate amount of time
- Quite a bit of the time
- All of the time
91. I have difficulty swallowing
- None of the time
- A little of the time
- A moderate amount of time
- Quite a bit of the time
- All of the time
92. I have pain behind my ear(s) (F on diagram)
- None of the time
- A little of the time
- A moderate amount of time
- Quite a bit of the time
- All of the time
93. I have facial pain when other joints are also sore
- None of the time
- A little of the time
- A moderate amount of time
- Quite a bit of the time
- All of the time
94. I have nervous problems
- None of the time
- A little of the time
- A moderate amount of time
- Quite a bit of the time
- All of the time
95. I have throbbing headaches
- None of the time
- A little of the time
- A moderate amount of time
- Quite a bit of the time
- All of the time
96. I feel dizzy
- None of the time
- A little of the time
- A moderate amount of time
- Quite a bit of the time
- All of the time
97. I consider myself to be a sickly person
- None of the time
- A little of the time
- A moderate amount of time
- Quite a bit of the time
- All of the time
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(801) 298-1812

Dr Montes seen both of my kids and was absolutely amazing, they felt no pain, very comfortable the whole time. They loved it there! They were both scared to go and now they both can't wait to go back!

Kierston Kirby

May 24, 2022.

I feel very fortunate to have found Dental Solutions. The dentists and the staff are outstanding! I have had health issues for many years and had this underlying, nagging feeling that was just exhausting. I went to Dental Solutions and had cavitation surgery and other dental work clean up, and that underlying nagging feeling is gone and my energy has returned! I would highly recommend them.

Tina Clifford

June 28, 2021.

The doctors and supporting staff are wonderful, and have helped me take control of my health through corrective dental work. It’s so nice to have a consultation with professionals who really care about you and your life!

Bonita Richins

June 18, 2021.

Dr Montes is a very knowledgeable dentist, and the whole staff is very fun and professional.

Coz

June 14, 2021.

The doctors and staff at Dental Solutions are exceptional. I have been going since 2015 and have received the best of care. Dr. Wall is a great dentist with much knowledge and expertise. He and the staff make sure you are comfortable and have all your questions answered. Kris is the best and most thorough hygienist. Highly recommend!

Marianne Austin

June 2, 2021.

Dr. Wall is a living legend in our family! He has helped me recover from poorly done root canals, fixed years worth of incorrect orthodontics, and solved my TMJ problems. I struggled with chronic vertigo during and after my pregnancy that was passed off as “normal” hormonal changes. I saw multiple doctors and neurologists before visiting Dr. Wall. He discovered 4 cavitations that needed addressing and once he worked his dental magic, the vertigo I had struggled with daily for 2 years disappeared! The importance of proper dental care for overall health cannot be overlooked. Dr. Wall is the best in his field and it’s an honor to have him on my healthcare team!

Missy Beavers

May 26, 2021.

I highly recommend Dr. Wall to anybody with tooth aches or pains. He is so caring and understanding. He has genuine concern for my well being. His staff is very nice and professional. I can't say enough good things about the care I received from Dr. Judson Wall and his team. Thank-you!

Tyler Heath

I had so much discomfort for years and Dr Wall took out teeth that were gangrene that I did not know were that bad. He is amazing....

Beatrice Ireland

May 24, 2021.

Hands down the most amazing dentist I've ever been to. From the expertise of care and heartfelt communication from Dr. Wall and his staff to the lush jungle of plants throughout the office, this is a dental experience like no other. For 15 years I had been struggling with a phantom disease causing chronic fatigue, brain fog, anxiety, depression, etc...it was hell. A woman (who I now feel is certainly a guardian angel) brought to my attention that my story was almost identical to the man who produced the film "Root Cause". I was taken aback that my issues could actually be caused by an old root canal I had and felt compelled to watch it...it made me cry and I knew this was it. She then referred me to Dr. Wall and the rest is history. I spent about 4 hours at Dental Solutions my first visit where I received a level of care you wouldn't expect from a dentist, let alone your family doctor. Being a biological practice, Dental Solutions has your whole body in mind and I was tested from head to toe to figure out what was going wrong. Sure enough, I had a failed root canal that had eaten a 1 cm diameter hole in my jaw above that tooth...it was slowly killing me. Dr. Wall pulled the decayed tooth which was gangrenous, cleaned everything out, stuffed the decayed hole with platelet rich fiber (PRF) and put a zirconia implant in. He also cleaned out my wisdom tooth cavitations and did TMJ injections to help the jaw issues I didn't realize I had. Over one year later and I feel better than ever, I have my vitality back!!!! So very thankful for Dr. Wall, he saved my life. No other dentist had any idea what was going on. This is the place to go, I travel from Colorado to come here...highly recommend this practice. Thank you Dental Solutions for changing my life!

Alex Curry

May 13, 2021.

235 South 400 East, Bountiful, Utah, 84010

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