Pre-Trial Patient Questionnaire
JawGuard TMD assessment form.
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Patient Name *
Patient Address
Patient Email Address
Patient Date of Birth
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Patient Gender
Clear selection
Do you suffer from any of the following conditions? (please tick as appropriate) *
Required
Have you ever undergone orthodontic treatment (tooth straightening)? *
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? *
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? *
Is there anything that makes your jaw associated pain worse? *
Please choose where you have experienced jaw or mouth related pain. *
Required
Do you ever experience a creaking or crunching noise from your jaw when speaking or eating? *
Have you ever experienced tightness or a reduction in how far you can open your mouth? *
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​? *
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? *
Have you ever altered your eating habits because of problems with your jaw, teeth or mouth? *
Have you ever had an interruption to your sleep because of problems with your jaw, teeth or mouth? *
Have you ever felt depressed because of problems with your jaw, teeth or mouth? *
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”: *
I still enjoy the things I used to enjoy: *
I get a frightened feeling as if something awful is about to happen *
I can laugh and see the funny side of things *
Worrying thoughts go through my mind: *
I feel cheerful
Clear selection
I can sit at ease and feel relaxed *
I feel as though I am slowed down *
I get a sort of frightened feeling like butterflies in the stomach *
I have lost interest in my appearance *
I feel restless and feel I have to be on the move all the time *
I look forward with enjoyment to things *
I get a sudden feeling of panic *
I can enjoy a good book or radio or TV programme *
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