TMD Evaluation Form

First name

Last name

Birthday

Year

Month

Day

Email

Phone

Address

Do you experience any of the following?

Describe your symptoms in your own words

How long have you had these symptoms?

In your opinion, what if anything first caused this problem?

Drescribe any other associate symptoms (headaches, ringing, whooshing sounds etc)

Have you ever seen a medical professional about your jaw/facial pain? If so which type of professional and when?

Have you previously had any of the following treatments/ procedures?

If you experience jaw locking does your jaw lock:

Fully closed

Partially closed (can open only partially up to a point)

Locks Open

Have you had any head or neck surgeries? If so please detail, what procedure and when.

Have you had an imaging (X rays, MRI etc) of your head, neck or jaw? if so when and with which radiologists?

The following section is not compulsory however these photos and videos are very helpful for providing a full 'picture' of your condition.

Please upload photos or a video of your face in a relaxed position from the front and each side.

Please upload a video of you slowly opening and closing your mouth fully taken from directly in front of you.

Please upload a video of you slowly moving your jaw side to side as far as you can without pain.

Please upload a video of you slowly moving your bottom jaw as far forward as you can without pain.