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

Id
Date

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 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?

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?

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?

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)?

Does your bite feel uncomfortable or unusual?

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?