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Jaw Function Limitation Scale

First name

Last name

Birthday

Year

Month

Day

Email*

Phone*

Address

The JFLS is a tool for determining the severity and impact of your condition on your quality of life. Based on the last month please indicate the level of limitation for each activity. If an activity has been avoided all together due to pain or difficulty select 10. Leave blank any activities you avoid for reasons other than pain or difficulty.

0= No Limitation

10= Severe Limitation

Chew tough food

0

1

2

3

4

5

6

7

8

9

10

Chew hard bread

0

1

2

3

4

5

6

7

8

9

10

Chew cooked chicken

0

1

2

3

4

5

6

7

8

9

10

Chew crackers

0

1

2

3

4

5

6

7

8

9

10

Chew soft food

0

1

2

3

4

5

6

7

8

9

10

Eat soft food not requiring chewing (mashed potatoes, apple sauce, pudding, pureed food)

0

1

2

3

4

5

6

7

8

9

10

Open wide enough to take a bite out of a whole apple

0

1

2

3

4

5

6

7

8

9

10

Open wide enough to bite into a sandwich

0

1

2

3

4

5

6

7

8

9

10

Open wide enough to talk

0

1

2

3

4

5

6

7

8

9

10

Open wide enough to drink from a cup

0

1

2

3

4

5

6

7

8

9

10

Swallow

0

1

2

3

4

5

6

7

8

9

10

Yawn

0

1

2

3

4

5

6

7

8

9

10

Talk

0

1

2

3

4

5

6

7

8

9

10

Sing

0

1

2

3

4

5

6

7

8

9

10

Putting on a happy face

0

1

2

3

4

5

6

7

8

9

10

Putting on an angry face

0

1

2

3

4

5

6

7

8

9

10

Frown

0

1

2

3

4

5

6

7

8

9

10

Kiss

0

1

2

3

4

5

6

7

8

9

10

Smile

0

1

2

3

4

5

6

7

8

9

10

Laugh

0

1

2

3

4

5

6

7

8

9

10

Bradford Chiropractic

TMJ
Sports
General Chiropractic Care

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