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Ivy House, Tanworth-in-Arden, Solihull, B94 5AL
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Virtual Consultation
01564 742 787
01564 742 787
About Us
The Clinic
Meet The Team
News
Local Partners
Blog
Treatments
Facial Treatments
Facial Aesthetics
Dermal Fillers
Lipofirm Plus
Comcit
Skin Needling
Weight Management & Healthy Lifestyle
Anti-Sweat Injections
Dental
Dental Check Up
Root Canals
Teeth Straightening
Invisalign
Cfast
Dental Implants
Teeth Whitening
Dental Emergency
Dental Hygienist
Children
Prices
Facial Aesthetic Fees
Dental Fees
Denplan
Before & Afters
Testimonials
Contact
TMD Assessment
jamestodd
2021-05-26T11:22:36+00:00
01564 742 787
Virtual Consultations
Contact us
TMD/TMJ Assessment
Please Fill Out The Form Below
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TMD Assessment
Assessment Form
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Order Number
Patient Name
*
Phone Number
History Of Complaint
*
Patient Oral Health Impact Profile-2 2 Questionnaire.
Pain Experienced During The Day/Night?
*
Day
Night
Day & Night
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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