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Ivy House, The Green, Tanworth-in-Arden, Solihull, B94 5AL
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Virtual Consultation
01564 742 787
01564 742 787
About Us
Meet The Team
News
Local Partners
Treatments
Facial Treatments
Facial Aesthetics
Dermal Fillers
Lipofirm Plus
Skin Needling
Weight Management & Healthy Lifestyle
Anti-Sweat Injections
Dental
Dental Check Up
Root Canals
Teeth Straightening
Dental Implants
Teeth Whitening
Dental Emergency
Dental Hygienist
Children
Denplan
Prices
Facial Aesthetic Fees
Dental Fees
Before & Afters
Testimonials
Contact
TMD Assessment
jamestodd
2020-12-07T14:19:14+00:00
TMD/TMJ Assessment
Please Fill Out The Form Below
Book Today
01564 742 787
Assessment Form
Order Number
Patient Name
*
Phone Number
*
History Of Complaint
*
Pain Experienced During The Day/Night?
*
Day
Night
Day & Night
Patient Oral Health Impact Profile-2 2 Questionnaire.
Do You Have Any Problems Chewing Any Foods?
*
0 - Never
1 - Hardly Ever
2 - Occasionally
3 - Fairly Often
4 - Very Often
Do You Find It Uncomfortable To Eat Any Foods?
*
0 - Never
1 - Hardly Ever
2 - Occasionally
3 - Fairly Often
4 - Very Often
Do You Find You Have To Avoid Eating Some Foods?
*
0 - Never
1 - Hardly Ever
2 - Occasionally
3 - Fairly Often
4 - Very Often
Does Jaw Pain Interrupt Meals?
*
0 - Never
1 - Hardly Ever
2 - Occasionally
3 - Fairly Often
4 - Very Often
Have You Had Difficulties In Opening And Closing Your Mouth?
*
0 - Never
1 - Hardly Ever
2 - Occasionally
3 - Fairly Often
4 - Very Often
Have You Had Any Painful Aching In Your Mouth Or Jaw?
*
0 - Never
1 - Hardly Ever
2 - Occasionally
3 - Fairly Often
4 - Very Often
Have You Had A Sore Jaw?
*
0 - Never
1 - Hardly Ever
2 - Occasionally
3 - Fairly Often
4 - Very Often
Do You Suffer With Headaches?
*
0 - Never
1 - Hardly Ever
2 - Occasionally
3 - Fairly Often
4 - Very Often
Have You Felt Speech Was Painful Because Of Problems With Your Teeth, Mouth, Dentures Or Jaws?
*
0 - Never
1 - Hardly Ever
2 - Occasionally
3 - Fairly Often
4 - Very Often
Are You Worried By Dental Problems?
*
0 - Never
1 - Hardly Ever
2 - Occasionally
3 - Fairly Often
4 - Very Often
Are You Self-Conscious About Your Jaw?
*
0 - Never
1 - Hardly Ever
2 - Occasionally
3 - Fairly Often
4 - Very Often
Have Jaw Problems Made You Miserable?
*
0 - Never
1 - Hardly Ever
2 - Occasionally
3 - Fairly Often
4 - Very Often
Have You Felt Tense Because Of Jaw Problems?
*
0 - Never
1 - Hardly Ever
2 - Occasionally
3 - Fairly Often
4 - Very Often
Has Your Sleep Been Interrupted?
*
0 - Never
1 - Hardly Ever
2 - Occasionally
3 - Fairly Often
4 - Very Often
Have You Been Upset Because Of Your Jaw/Facial Discomfort?
*
0 - Never
1 - Hardly Ever
2 - Occasionally
3 - Fairly Often
4 - Very Often
Do You Find It Difficult To Relax?
*
0 - Never
1 - Hardly Ever
2 - Occasionally
3 - Fairly Often
4 - Very Often
Do You Feel Depressed ?
*
0 - Never
1 - Hardly Ever
2 - Occasionally
3 - Fairly Often
4 - Very Often
Has Your Concentration Been Affected?
*
0 - Never
1 - Hardly Ever
2 - Occasionally
3 - Fairly Often
4 - Very Often
Do You Become A Bit Irritable With Other People?
*
0 - Never
1 - Hardly Ever
2 - Occasionally
3 - Fairly Often
4 - Very Often
Do You Have Difficulty Doing Your Usual Jobs?
*
0 - Never
1 - Hardly Ever
2 - Occasionally
3 - Fairly Often
4 - Very Often
Do You Find Life In General Less Satisfying?
*
0 - Never
1 - Hardly Ever
2 - Occasionally
3 - Fairly Often
4 - Very Often
Are You Unable To Work To Your Full Capacity Because Of Jaw/Facial Pain?
*
0 - Never
1 - Hardly Ever
2 - Occasionally
3 - Fairly Often
4 - Very Often
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