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Pre Trial Clinical Assessment - Patient History and Examination
TMD Diagnostics
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* Indicates required question
Email
*
Your email
Patient Name
*
Your answer
Patient Address
Your answer
Date of birth
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MM
/
DD
/
YYYY
Gender
*
Male
Female
Prefer not to say
Email Address
*
Your answer
Presenting complaint in patients own words.
*
Your answer
HPC - How long have you had jaw related pain?
Your answer
Is the pain constant or does it come and go?
Your answer
How often do you experience symptoms?
*
Very often
Often
Occasionally
Rarely
Never
Is there a time your symptoms are worse?
Morning
Evening
After eating
It's farily random
Clear selection
Do your symptoms affect your sleep?
Yes
No
Sometimes
Clear selection
How would you describe the nature of the pain you experience? (eg short sharp stabbing, background ache, tenderness etc)
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Your answer
Can you localise the pain/discomfort?
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Yes
No
Maybe
If so where is the focus of the pain?
Your answer
Does anything trigger the pain/ discomfort?
*
Your answer
Does anything make the pain/discomfort better?
*
Your answer
Does anything make the pain/ discomfort worse?
Your answer
Do you have any other symptoms associated with the pain or discomfort?
Your answer
Do you experience any clicking in the jaw?
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Yes
No
If yes please answer the following: do you get pain associated with the click?
Yes
No
Sometimes
Is the click on a particular side?
*
Right hand side
Left hand side
Both
Can't tell
Has there been any change in your life or increased stress levels?
Yes
No
Unsure
Clear selection
Do you suffer from any ear problems such as infections or tinnitus (ringing in your ears)?
*
Yes
No
Have you had treatment for jaw related problems in the past? If so please describe your treatment and whether it helped.
*
Your answer
Inter – incisal distance on 1st opening (in mm)
Your answer
Is there pain on opening?
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Yes
No
Inter – incisal distance on maximal stretch ( in mm)
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Your answer
Is there pain at stretch?
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Yes
No
Clicking or crepitus on opening/closing?
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Opening
Closing
Neither
Both
Deviation from the midline on opening?
*
None
Deviates to the left
Deviates to the right
Overjet (in mm - if reverse overjet please indicate with a negative value)
Your answer
Overbite in mm (if anterior open bite please indicate)
Your answer
Skeletal Class
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I
II
III
Masseteric hypertrophy present?
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Yes
No
Masseteric tenderness on palpatation?
Yes RHS
Yes LHS
Both
No
Clear selection
Temporalis hypertrophy present?
*
Yes
No
Temporalis tenderness on palpatation?
Yes RHS
Yes LHS
Both
No
Clear selection
Sternocleidomastoid hypertrophy present?
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Yes
No
Sternocleidomastoid tenderness on palpatation?
Yes RHS
Yes LHS
Both
No
Clear selection
Lateral pterygoid tenderness (if possible)
*
Yes RHS
Yes LHS
Both
No
Tongue scalloping present?
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Yes
No
Is tooth wear present? If so what is the pattern and location of the wear?
*
Your answer
Linea alba present on buccal mucosa?
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Yes
No
Does the patient have a history of chipped or broken teeth?
*
Yes
No
Any other comments?
Your answer
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