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Temporomandibular Joint (TMJ) History

Note that this questionairre is not a substitute for professional medical diagnosis, but provided as a service to help individuals learn more about TMJ and to make informed and intelligent decisions when diagnosis and treatment options are presented by Dr. Barry. No information you provide here is transmitted to any party.

Answer the following questions below, then click "Submit".

General Questions   Check all that apply

Tension Headaches
Sinus Headaches (Pain Pressure Behind Eyes)
Migranes
Facial Pain
Neck Pain
Shoulder Pain
Earaches
Ringing in ears
Dizziness
Previous Head or Jaw Injury
Pain or Difficulty Opeing Mouth Wide or Yawning    
Pain or Soreness when Chewing
Clicking or Popping in Jaws
Clinching or Grinding teech during day
Jaw sometimes locks open
Clinching or Grinding teeth during night
Awaking with Awareness of Teeth or Jaw
Teeth Sensitive to Biting Pressure
Teech are Sensitive to Cold
Bite Adjusted in the Past
Past Biteplane or Mouth Guard
Past treatment for Jaw, Head, or Neck Pain
Would you like help with above problem

Pain Symptoms

How Often Is Your Pain?
 
How intense is your pain?
 
Do you take any antidepressants, tranquilizers, or pain medication?
  Yes
  What and how often?
 
Where is your pain?
 
     

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Richard B. Barry, D.D.S. & Dr. Beth Love, D.D.S. 1234 Old Henderson Road Columbus, OH 43220
Phone: (614) 451-2234 Fax: (614) 451-1511 E-mail: drbarry@pearlywhitesmile.com

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