Pre Trial Clinical Assessment - Patient History and Examination
TMD Diagnostics
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Email *
Patient Name *
Patient Address
Date of birth *
Gender *
Email Address *
Presenting complaint in patients own words. *
HPC - How long have you had jaw related pain?
Is the pain constant or does it come and go?
How often do you experience symptoms? *
Is there a time your symptoms are worse?
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Do your symptoms affect your sleep?
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How would you describe the nature of the pain you experience? (eg short sharp stabbing, background ache, tenderness etc) *
Can you localise the pain/discomfort? *
If so where is the focus of the pain?
Does anything trigger the pain/ discomfort? *
Does anything make the pain/discomfort better? *
Does anything make the pain/ discomfort worse?
Do you have any other symptoms associated with the pain or discomfort?
Do you experience any clicking in the jaw? *
If yes please answer the following: do you get pain associated with the click?
Is the click on a particular side? *
Has there been any change in your life or increased stress levels?
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Do you suffer from any ear problems such as infections or tinnitus (ringing in your ears)? *
Have you had treatment for jaw related problems in the past? If so please describe your treatment and whether it helped. *
Inter – incisal distance on 1st opening (in mm)
Is there pain on opening? *
Inter – incisal distance on maximal stretch ( in mm) *
Is there pain at stretch? *
Clicking or crepitus on opening/closing? *
Deviation from the midline on opening? *
Overjet (in mm - if reverse overjet please indicate with a negative value)
Overbite in mm (if anterior open bite please indicate)
Skeletal Class *
Masseteric hypertrophy present? *
Masseteric tenderness on palpatation?
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Temporalis hypertrophy present? *
Temporalis tenderness on palpatation?
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Sternocleidomastoid hypertrophy present? *
Sternocleidomastoid tenderness on palpatation?
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Lateral pterygoid tenderness (if possible) *
Tongue scalloping present? *
Is tooth wear present? If so what is the pattern and location of the wear? *
Linea alba present on buccal mucosa? *
Does the patient have a history of chipped or broken teeth? *
Any other comments?
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