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(801) 298-1812
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TMJ Scale
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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