Pre-Trial Patient Questionnaire

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JawGuard TMD assessment form.

Patient Name *

Patient Address

Patient Email Address

Patient Telephone Number *

Patient Date of Birth

YYYY

Gender

Female

Male

Prefer not to say

Clear selection

Do you suffer from any of the following conditions? (please tick as appropriate) *

Headaches

Fibromyalgia

Chronic back pain

Irritable bowel syndrome

Stress/anxiety

Depression

Earache/tinnitus

Neck/shoulder pain

Other:

Required

Have you ever undergone orthodontic treatment (tooth straightening)? *

Yes

Have you ever had an injury to your face, jaw or teeth? (Yes/No) If yes please describe: *

Do you ever suffer with generalised pain or aching from your teeth or jaw? *

Never

Hardly ever

Occasionally

Fairly often

Very often

On a scale of 1 – 10 with 10 being the most pain you have ever felt, what is the worst pain you’ve had from your teeth or jaw? *

Have you ever needed to take pain relief such as ibuprofen or paracetamol for any jaw pain? *

Yes

Is there anything that makes your jaw associated pain worse? *

Please choose where you have experienced jaw or mouth related pain. *

Temples

Ear

Behind the eyes

Jaw joint

Teeth

Below the ear

Jaw muscles

Underneath the chin

Neck

Cheeks

In front of the ear.

Other:

Required

Do you ever experience a creaking or crunching noise from your jaw when speaking or eating? *

Never

Hardly ever

Occasionally

Fairly often

Very often

Have you ever experienced tightness or a reduction in how far you can open your mouth? *

Never

Hardly ever

Occasionally

Fairly often

Very often

On a scale of 1 – 10 with 10 being unable to open your mouth at all and 1 being normal and comfortable opening, how would you rate your ability to open your mouth? *

Have you ever found chewing uncomfortable or difficult? *

Never

Hardly ever

Occasionally

Fairly often

Very often

On a scale of 1 – 10 with 10 being unable to chew anything, how would you rate your ability to chew? *

On a scale of 1 – 10 with 10 being intensely worried, how would you rate how much you have worried about jaw or dental problems? *

On a scale of 1 – 10 with 10 being intensely self conscious, how would you rate how much self conscious you have been because of your jaw, teeth or mouth? *

Have you felt miserable because of jaw or dental problems? *

Never

Hardly ever

Occasionally

Fairly often

Very often

Have you ever altered your eating habits because of problems with your jaw, teeth or mouth? *

Never

Hardly ever

Occasionally

Fairly often

Very often

Have you ever had an interruption to your sleep because of problems with your jaw, teeth or mouth? *

Never

Hardly ever

Occasionally

Fairly often

Very often

Have you ever felt depressed because of problems with your jaw, teeth or mouth? *

Never

Hardly ever

Occasionally

Fairly often

Very often

On a scale from 1 – 10 with 10 being unable to do any work, how would you rate how problems with your jaw, teeth or mouth have affected you doing your normal job? *

On a scale of 1 – 10 with 10 being 100% affected, how would you rate the effect of jaw or mouth problems has on your overall quality of life? *

I feel tense or “wound up”: *

Most of the time

From time to time, occasionally

A lot of the time

Not at all

I still enjoy the things I used to enjoy: *

Definitely as much

Not quite so much

Only a little

Hardly at all

I get a frightened feeling as if something awful is about to happen *

Very definitely and quite badly

Yes, but not too badly

A little, but it doesn’t worry me

Not at all

I can laugh and see the funny side of things *

As much as I always could

Not quite so much now

Option 3

Definitely not so much now

Not at all

Worrying thoughts go through my mind: *

A great deal of the time

A lot of the time

From time to time, but not too often

Only occasionally

I feel cheerful

Not at all

Not often

Sometimes

Most of the time

Clear selection

I can sit at ease and feel relaxed *

Definitely

Usually

Not often

Not at all

I feel as though I am slowed down *

Nearly all of the time

Very often

Sometimes

Not at all

I get a sort of frightened feeling like butterflies in the stomach *

Not at all

Occasionally

Quite often

Very often

I have lost interest in my appearance *

Definitely

I don’t take as much care as I should

I may not take quite as much care

I take just as much care as ever

I feel restless and feel I have to be on the move all the time *

Very much indeed

Quite a lot

Not very much

Not at all

I look forward with enjoyment to things *

As much as I ever did

Rather less than I used to

Definitely less than I used to

Hardly at all

I get a sudden feeling of panic *

Very often indeed

Quite often

Not very often

Not at all

I can enjoy a good book or radio or TV programme *

Often

Sometimes

Not often

Very seldom

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