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About Us
Meet Dr. Ara Gulesserian, D.D.S.
Meet Dr. Maggie Pezeshkian, D.C.
Our Office
Treatments
Dental
Temporomandibular Joint Disorders (TMJ/TMD) and Treatments
Oral Appliance Therapy for Sleep Apnea
Dental Trauma
Customized Mouthguards
Chiropractic
Chiropractic Care
Massage Therapy
Myofascial Pain Syndrome
Neck Pain and Headaches
Joint Pain
Musculoskeletal Sports Injury
Workplace Injuries
Care After Auto Accidents
Comprehensive TMJ and Head & Neck Muscle Evaluation
Resources
Patient Information
Testimonials
Contact Us
Menu
Home
About Us
Meet Dr. Ara Gulesserian, D.D.S.
Meet Dr. Maggie Pezeshkian, D.C.
Our Office
Treatments
Dental
Temporomandibular Joint Disorders (TMJ/TMD) and Treatments
Oral Appliance Therapy for Sleep Apnea
Dental Trauma
Customized Mouthguards
Chiropractic
Chiropractic Care
Massage Therapy
Myofascial Pain Syndrome
Neck Pain and Headaches
Joint Pain
Musculoskeletal Sports Injury
Workplace Injuries
Care After Auto Accidents
Comprehensive TMJ and Head & Neck Muscle Evaluation
Resources
Patient Information
Testimonials
Contact Us
Request Appointment
TMJ Questionnaire
Request appointment
Name
Date
Age
Phone Number
Email
Do you have TMJ noises when you open and close your mouth?
No
Yes
Is the pain:
Mild
Moderate
Severe
Are the noises
Clicking
Popping
Grinding
Are the noises
Mild
Moderate
Severe
Is the pain in the TMJ on the:
Left
Right
Are the TMJ noises on the:
Left
Right
Do you have jaw joint (TMJ) pain?
No
Yes
When did your jaw joint problems (i.e., pain, noises, headache) begin?
What started your jaw joint problems?
Injury
Disease
Unknown
Have you had previous TMJ surgery?
No
Yes
How many operations?
Have your jaw alignment or bite changed?
No
Yes
How much change?
Mild
Moderate
Severe
Do you get headaches?
No
Yes
Are the headaches:
Mild
Moderate
Severe
Are your headaches worse in the:
Morning
Afternoon
Afternoon
Night
No Difference
Are they:
Occasional
Frequent
Constant
Where do the headaches occur?
Left Forehead
Right Forehead
Left Temple
Right Temple
Back of the Head
Top of Head
Behind Left Eye
Behind Right Eye
Do you have:
Neck
Shoulder
Back pain
Is the pain:
Mild
Moderate
Severe
Do you clench your teeth at night?
No
Yes
Do you clench your teeth at during the day?
No
Yes
Is your clenching/grinding:
Mild
Moderate
Severe
Do you get earaches?
No
Yes
On which side?
Left
Right
Are they:
Mild
Moderate
Severe
Do they occur:
Occasionally
Moderately
Frequently
Continuously
Do you get ringing in your ears?
No
Yes
Is the ringing:
Mild
Moderate
Severe
Does it occur:
Occasionally
Moderately
Frequently
Continuously
Do you get lightheadedness or dizziness?
No
Yes
Is it:
Mild
Moderate
Severe
Does it occur:
Occasionally
Moderately
Frequently
Continuously
Do you suffer from depression?
No
Yes
Are you under treatment for depression?
No
Yes
Do you have problems with other joints?
No
Yes
Circle the number that best describes your situation: 0 = No pain, 10 = Worse Pain Imaginable
TMJ pain
1
2
3
4
5
6
7
8
9
10
Headache
1
2
3
4
5
6
7
8
9
10
Average daily pain for head and neck area
1
2
3
4
5
6
7
8
9
10
Rate your jaw function for opening side to side movement, and chewing Function Jaws Frozen
0 = Normal, 10 = No Function
1
2
3
4
5
6
7
8
9
10
What can you chew?
0 = Chew Anything, 10 = Cannot Chew
1
2
3
4
5
6
7
8
9
10
How much does your jaw problem affect your ability to carry out normal life activities? In Any Way
0 = No Interference, 10 = Totally Disabled
1
2
3
4
5
6
7
8
9
10
Send
