Temporomandibular Joint Dysfunction Screening Survey

Jaw joint dysfunction is a common problem that can severely impact a person’s lifestyle and confidence resulting in restricted physical and social functioning. People find it difficult to eat certain foods and restrict their diet often causing their diet to become unbalanced. People often avoid social settings such as dining out or other social settings where they may be talking frequently. Jaw joint problems can be caused by a wide range of problems such as head trauma, falls or whiplash injuries, and complications of other medical conditions.

All fields are required.

First Name

Surname

Address

Date of Birth

Contact Phone Number

Email Address

Are You A New Client?
YesNo

Are You A Member of a Health Fund?
YesNo

Workers Compensation?
YesNo

Third Party Insurance?
YesNo



About you...


Have you had a blow to your jaw?
YesNo

Have you had a whiplash injury?
YesNo

Have you had a severe bout of vomiting?
YesNo

Have you had your wisdom teeth removed?
YesNo

Have you had any major dental work done? (Had to have your mouth open a long time)YesNo

Have you had an anaesthetic for surgery?
YesNo

Have you started any new medications prior to your symptoms starting?
YesNo

Do you ever sleep on your back or your stomach?
YesNo

Do you read, watch TV, use a laptop/notepad or mobile phone in bed?
YesNo

Have you been under a lot of stress?
YesNo

Have you had a severe cough recently?
YesNo

Have you recently had a bout of sinus and been unable to breathe through your nose?
YesNo

Have ever been diagnosed with Temporomandibular Joint Dysfunction??
YesNo

Do you get frequent headaches?
YesNo



About your jaw joint, is it...


Do you get clicking, grating, popping or cracking noises when you open your mouth to speak, chew or yawn?
YesNo

Is your jaw joint or face sore or tired after eating?
YesNo

Is it difficult to open your mouth at times?
YesNo

Do you have pain in your jaw joint or face?
YesNo

Have you ever had your mouth stuck open?
YesNo

Does your jaw feel tight?
YesNo

Do you avoid eating hard or chewy food?
YesNo

Do you have unexplained teeth ache?
YesNo

Do you clench or grind your teeth
YesNo

Do you get regular earaches?
YesNo

Do you have neck pain?
YesNo

Do you get stuffy or blocked ears for no reason or need to pop your ears?
YesNo

Do you chew chewing gum often?
YesNo

Do you regularly eat hard or very chewy lollies?
YesNo

Do your teeth come together comfortably?
YesNo

Do you get sinus-like pain even though your sinuses are clear?
YesNo

Do you experience tinnitus?
YesNo

Please Enter The Code Below
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 This screening survey has been designed to assess the nature of your jaw joint and facial pain symptoms and determine treatable elements of your condition, thus assisting you to develop a management plan. The screening survey will take 5 minutes to complete and your answers will be confidential. When you have completed the survey, please enter the code in the box and click send appointment request.