TMJ Patient Diagnosis Form - Your Clinic - Prof. Dr. Mustafa TEK

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+90 216 642 4242info@profdrmustafatek.comAskerocağı Cad. No:6, Daire 149 (Süzer Plaza)Şişli, İstanbul

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Name

Birth Date

Address

Country

E-Mail

Phone

How are you experiencing issues with your jaw joints, jaw muscles, and/or teeth?

When did these issues start?

What do you think might be causing these issues?

SYMPTOMS

Please check off any symptoms that apply to you.

Clicking or popping sound in your joints

Grinding noises

Locking of your jaw when opening

Locking of your jaw when closed

Limited jaw opening

Difficulty in opening your jaw smoothly

Pain in the jaw joints

Pain in facial muscles

Teeth Problems

Tooth grinding

Teeth clenching

Pain in one or more teeth

Looseness in one or more teeth

Head and facial pain

Migraine-type headaches

Migraine-type headache – Pain severity

Selected value : 0

Slide to indicate pain severity.

All headache

All headache – Pain severity

Selected value : 0

Slide to indicate pain severity.

Sinus headaches

Sinus headaches – Pain severity

Selected value : 0

Slide to indicate pain severity.

Pain at the back of the head

Pain at the back of the head – Pain severity

Selected value : 0

Slide to indicate pain severity.

Tenderness of the scalp or hair follicles

Tenderness of the scalp or hair follicles – Pain severity.

Selected value : 0

Slide to indicate pain severity.

Ear or balance problems

Eye problems

Pain in Ear

Pain around or behind the eyes

Ringing or buzzing in the ears

Redness in the eyes

Clogged ears or feeling of fullness

Blurred vision

Hearing loss

Pressure behind the eyes

Dizziness or vertigo

Sensitivity to light

Balance disorder

Tearing in the eyes

Neck and/or shoulder pain

Throat problems

Neck/shoulder/back pain

Difficulty swallowing

Decreased range of motion in the neck/shoulder/back

Feeling of tightness in the throat

Frequent neck muscle fatigue

Throat pain

Tingling, numbness, pain in the arm or fingers

Tongue pain

Palate pain

PATIENT HEALTH INFORMATIONS

Have you experienced any recent or childhood traumas to your head or face (such as falls, traffic accidents, blows to the head or face, sports injuries, etc.)? If yes, please explain.

Do you have any activities that frequently put your head or neck in an awkward position (such as playing an instrument, using a keyboard, holding a phone, etc.)? If yes, please explain.

Have you received treatment for Temporomandibular Joint Disorder (TMD) before? If yes, when was it?

Was the issue the same as your current problem, or was it different?

What treatment did you receive?

Information about the treating doctor

Do you think the treatment was successful?

Selected value : 0

Could you rate your previous treatment on a scale of 1 to 10?

What are your expectations from the treatment that will be applied at our clinic?

Don’t hesitate to contact us with any inquiries. Our dedicated staff is ready to assist you with all your dental care needs and ensure you receive the best possible service.

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