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TMJ Evaluation Form

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56 views2 pages

TMJ Evaluation Form

Uploaded by

jannesiszeballos
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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DAVID K.

HUNTER, DDS
DEAN B. SPINGOLA, DMD, MD
CRAIG E. BUCHMANN, DDS
BRANDON R. BROWN, DDS
DIPLOMATES OF THE AMERICAN BOARD OF ORAL & MAXILLOFACIAL SURGERY
WWW.NTFOS.COM

Name ___________________________________________________________ Date of Birth _______________________________

1. Please explain the reason for your visit. _________________________________________________________________________

2. Are you currently under the care of or have been in the care of a physician within the last year?  Yes  No
If yes, please provide the following:
Physician’s Name _____________________________________ Treatment ______________________________________
Condition Treated _____________________________________ Medications ______________________________________

3. Dentist’s Name ________________________________________ Date of Last Appointment: ___________________________


Treatment prescribed ______________________________________________________________________________________

4. Please describe any problems with your jaw: ___________________________________________________________________


How long have you had these problems? _______________________________________________________________________

5. If you have received treatment for jaw problems, please indicate the treatment you received:
Treatment Yes No Results

Good Fair Poor


Bit Splint
Medication
Physical Therapy
Occlusal
Adjustment
Surgery
Other (specify)

Who directed this treatment? ___________________________________________________________________________________

6. Where is the pain?


 Ears In front of Ears Behind Ears Eyes Jaws  Teeth Neck Headache Nose Tongue Lips
When is it worse? AM PM Does it wake you at night?  Yes No
Rank your pain on a scale from 1 to 10: Least 1 2 3 4 5 6 7 8 9 10 Worse

Do you do anything to relieve your pain? Yes No If so, what? ___________________________________________________
What makes the pain worse? _________________________________________________________________________________

7. Do your jaw joints make noise? Yes No


Right Clicking Popping Grinding Other
Left Clicking Popping Grinding Other

8. Has your jaw every locked? Yes No If yes, when did it occur and how often has it occurred?
____________________________________________________________________________________________________________
9. Do you consider yourself to be under more stress than most people? Yes No
10. Please provide any additional information you feel may be helpful in your diagnosis or treatment.
____________________________________________________________________________________________________________

Patient Signature and Date _____________________________________________________________________________________


◆…Dental Implants…Wisdom Teeth…Dentoalveolar Surgery…Extractions…Pathology…Corrective Jaw Procedures…Reconstruction…Trauma…◆

GRAPEVINE Baylor Regional Medical Center 1612 Lancaster Drive, Grapevine, TX 76051 (817) 329-4979
IRVING Baylor Health Center at Irving-Coppell 440 West Interstate Hwy 635, Suite 445 Irving, TX 75063 (972) 401-8301
KELLER Centerview Office Park 1139 Keller Parkway Keller, TX 76248 (817) 379-1654
TMJ Evaluation Form

VO pain free ______ mm Max Opening ______ mm

Deviation opening: None RT ______ mm LT ______ mm

Lateral Movement: RT ______ mm LT ______ mm

Protrusive: ______ mm Deviation RT ______ mm LT ______ mm

Joint Sounds: Click RT ______ mm LT ______ mm


Pop RT ______ mm LT ______ mm

Lock: Yes or No

Translation: NL RT LT
Joint Pain: Lateral RT LT
Ear RT LT
Muscle Pain: Temporalis RT LT
Masseter RT LT
Ptergoid RT LT
SCM RT LT
Cervical RT LT
Coronoid RT LT

Oral Exam: Occlusion: Class I______


Class II______
Class III______

Cross bite: Yes or No Wear: Yes or No

Missing Teeth: ___________________________

Neurologic Exam: Trigger Points Yes or No Location ___________________________

Assessment: Articular Disc Disorder 524.63; Myalgia & Myositis 729.1;

Capsulitis 726.90, Dislocation 830.0

Images: PANO TOMO CEPH MRI ICAT

Plan: MRI ICSH TCMC OTHER

ARTHROSCOPY ARTHROPLASTY ARTHROCENTESIS

Facility: ICSH TCMC OTHER

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