Please read each question and respond accordingly. For each of the questions below circle only one response.

Date

Would you say your health in general is excellent, very good, good, fair or poor?

N/A

Excellent

Very good

Good

Fair

Poor

Would you say your oral health in general is excellent, very good, good, fair or poor?

N/A

Excellent

Very good

Good

Fair

Poor

Have you had pain in the face, jaw, temple, in front of the ear or in the ear in the past month?

Yes

How many years ago did your facial pain begin for the first time?

Years

How many months ago did your facial pain begin for the first time?

Months

Is your facial pain persistent, recurrent or was it only a one-time problem?

N/A

Persistent

Recurrent

One time

Have you ever gone to a physician, dentist, chiropractor or other health professional for facial ache or pain?

N/A

Last six months

More than six months

How would you rate your facial pain on a 0 to 10 scale at the present time, that is right now, where 0 is "no pain" and 10 is "pain as bad as could be"?

In the past six months, how intense was your worst pain rated on a 0 to 10 scale where 0 is "no pain" and 10 is "pain as bad as could be"?

In the past six months, on the average, how intense was your pain rated on a 0 to 10 scale where 0 is "no pain" and 10 is "pain as bad as could be"? [That is, your usual pain at times you were experiencing pain].

About how many days in the last six months have you been kept from your usual activities (work, school or housework) because of facial pain?

Days

In the past six months, how much has facial pain interfered with your daily activities rated on a 0 to 10 scale where 0 is "no interference" and 10 is "unable to carry on any activities"?

In the past six months, how much has facial pain changed your ability to take part in recreational, social and family activities where 0 is "no interference " and 10 is "extreme change"?

In the past six months, how much has facial pain changed your ability to work including housework) where 0 is "no interference " and 10 is "extreme change"?

Have you ever had your jaw lock or catch so that it won't open all the way?

Yes

If no problem opening all the way continue here

Was this limitation in jaw opening severe enough to interfere with your ability to eat?

Yes

Does your jaw click or pop when you open or close your mouth or when chewing?

Yes

Does your jaw make a grating or grinding noise when it opens and closes or when chewing?

Yes

Have you been told, or do you notice that you grind your teeth or clench your jaw while sleeping at night?

Yes

During the day, do you grind your teeth or clench your jaw?

Yes

Does your jaw ache or feel stiff when you wake up in the morning?

Yes

Do you have noises or ringing in your ears?

Yes

Does your bite feel uncomfortable or unusual?

Yes

Do you have rheumatoid arthritis, lupus, or other systemic arthritic disease?

Yes

Do you know of anyone in your family who has had any of these diseases?

Yes

Have you had or do you have any swollen or painful joint(s) other than the joints close to your ears (TMJ)?

Yes

If no swollen or painful joints continue here

Is this a persistent pain which you have had for at least one year?

Yes

Have you had a recent injury to your face or jaw?

Yes

If no recent injuries continue here

Did you have jaw pain before the injury?

Yes

During the last six months have you had a problem with headaches or migraines?

Yes

What activities does your present jaw problem prevent or limit you from doing?

Chewing

Drinking

Exercising

Eating Hard Foods

Eating Soft Foods

Smiling/laughing

Sexual activity

Cleaning teeth or face

Yawning

Swallowing

Talking

Having your usual facial appearance

In the last month, how much have you been distressed by...

Headaches

0 1 2 3 4

Loss of sexual interest or pleasure

0 1 2 3 4

Faintness or dizziness

0 1 2 3 4

Pains in the heart or chest

0 1 2 3 4

Feeling low in energy or slowed down

0 1 2 3 4

Thoughts of death or dying

0 1 2 3 4

Poor appetite

0 1 2 3 4

Crying easily

0 1 2 3 4

Blaming yourself for things

0 1 2 3 4

Pains in the lower back

0 1 2 3 4

Feeling lonely

0 1 2 3 4

Feeling blue

0 1 2 3 4

Worrying too much about things

0 1 2 3 4

Feeling no interest in things

0 1 2 3 4

Nausea or upset stomach

0 1 2 3 4

Soreness of your muscles

0 1 2 3 4

Trouble falling asleep

0 1 2 3 4

Trouble getting your breath

0 1 2 3 4

Hot or cold spells

0 1 2 3 4

Numbness or tingling in parts of your body

0 1 2 3 4

A lump in your throat

0 1 2 3 4

Feeling hopeless about the future

0 1 2 3 4

Feeling weak in parts of your body

0 1 2 3 4

Heavy feelings in your arms or legs

0 1 2 3 4

Thoughts of ending your life

0 1 2 3 4

Overeating

0 1 2 3 4

Awakening in the early morning

0 1 2 3 4

Sleep that is restless or disturbed

0 1 2 3 4

Feeling everything is an effort

0 1 2 3 4

Feelings of worthlessness

0 1 2 3 4

Feeling of being caught or trapped.

0 1 2 3 4

Feelings of guilt

0 1 2 3 4

How good a job do you feel you are doing in taking care of your health overall?

N/A

Excellent

Very good

Good

Fair

Poor

How good a job do you feel you are doing in taking care of your oral health?

N/A

Excellent

Very good

Good

Fair

Poor

Do you have pain on the right side of your face, the left side or both sides?

None

Right

Left

Both

Could you point to the areas where you feel pain?

Rigth

None

Jaw joint

Muscles

Both

Left

None

Jaw joint

Muscles

Both

Opening Pattern

Straight Uncorrected Right lateral deviation

Corrected (S) Right lateral deviation

Uncorrected Left lateral deviation

Corrected (S) Left lateral deviation

Other

Vertical range motion

Unassisted opening without pain mm

Maximum unassisted opening mm

Maximum assisted opening mm

Vertical incisal overlap mm

Excursions

Right Lateral Excursion mm

Left Lateral Excursion mm

Protrusion mm

Midline Deviation

Deviation mm

Right

Left

N/A

Joint sounds excursions

Directions for next items

The examiner will be palpating (touching) different areas of your face, head and neck. We would like you to indicate if you do not feel pain or just feel pressure (0), or pain (1-3). Please rate how much pain you feel for each of the palpations according to the scale below. Circle the number that corresponds to the amount of pain you feel. We would like you to make a separate rating for both the right and left palpations.
0 = No Pain/Pressure Only
1 = Mild Pain
2 = Moderate Pain
3 = Severe Pain

Extraoral muscle pain with palpation

Temporalis

Right

Left

Masseter

Right

Left

Joint pain with palpation

Lateral pole "outside"

Right

Left

Intraoral muscle pain with palpation

Lateral pterygoid area "Behind upper molars"

Right

Left

Tendon of temporalis "Tendon"

Right

Left

Please read each question and respond accordingly. For each of the questions below circle only one response.

Would you say your health in general is excellent, very good, good, fair or poor?

Would you say your oral health in general is excellent, very good, good, fair or poor?

Have you had pain in the face, jaw, temple, in front of the ear or in the ear in the past month?

How many years ago did your facial pain begin for the first time?

How many months ago did your facial pain begin for the first time?

Is your facial pain persistent, recurrent or was it only a one-time problem?

Have you ever gone to a physician, dentist, chiropractor or other health professional for facial ache or pain?

How would you rate your facial pain on a 0 to 10 scale at the present time, that is right now, where 0 is "no pain" and 10 is "pain as bad as could be"?

In the past six months, how intense was your worst pain rated on a 0 to 10 scale where 0 is "no pain" and 10 is "pain as bad as could be"?

In the past six months, on the average, how intense was your pain rated on a 0 to 10 scale where 0 is "no pain" and 10 is "pain as bad as could be"? [That is, your usual pain at times you were experiencing pain].

About how many days in the last six months have you been kept from your usual activities (work, school or housework) because of facial pain?

In the past six months, how much has facial pain interfered with your daily activities rated on a 0 to 10 scale where 0 is "no interference" and 10 is "unable to carry on any activities"?

In the past six months, how much has facial pain changed your ability to take part in recreational, social and family activities where 0 is "no interference " and 10 is "extreme change"?

In the past six months, how much has facial pain changed your ability to work including housework) where 0 is "no interference " and 10 is "extreme change"?

Have you ever had your jaw lock or catch so that it won't open all the way?

Was this limitation in jaw opening severe enough to interfere with your ability to eat?

Does your jaw click or pop when you open or close your mouth or when chewing?

Does your jaw make a grating or grinding noise when it opens and closes or when chewing?

Have you been told, or do you notice that you grind your teeth or clench your jaw while sleeping at night?

During the day, do you grind your teeth or clench your jaw?

Does your jaw ache or feel stiff when you wake up in the morning?

Do you have noises or ringing in your ears?

Does your bite feel uncomfortable or unusual?

Do you have rheumatoid arthritis, lupus, or other systemic arthritic disease?

Do you know of anyone in your family who has had any of these diseases?

Have you had or do you have any swollen or painful joint(s) other than the joints close to your ears (TMJ)?

Is this a persistent pain which you have had for at least one year?

Have you had a recent injury to your face or jaw?

Did you have jaw pain before the injury?

During the last six months have you had a problem with headaches or migraines?

What activities does your present jaw problem prevent or limit you from doing?

In the last month, how much have you been distressed by...

How good a job do you feel you are doing in taking care of your health overall?

How good a job do you feel you are doing in taking care of your oral health?

Do you have pain on the right side of your face, the left side or both sides?

Could you point to the areas where you feel pain?

Opening Pattern

Vertical range motion

Joint sounds

Opening

Closing

Excursions

Joint sounds excursions

Directions for next items

Extraoral muscle pain with palpation

Joint pain with palpation

Intraoral muscle pain with palpation