Musculoskeletal � Occlusal Signs Exam Form by 8d4fP1

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									          TMJ / TMD Signs Exam Form
        Great Oaks Family & Cosmetic Dentistry
  15930 Great Oaks Drive, Suite A-100, Round Rock, Texas 78681 (512) 255-3800

Name: ______________________________

SYMPTOMS
  □ Frequent Headaches (Migraines)
  □ Soreness at jaw joint located in front of ear opening
  □ Popping or Clicking of the jaw joint
  □ Limited Opening of your mouth
  □ Ear Congestion
  □ Dizziness
  □ Ringing in the ear
  □ Difficulty Swallowing
  □ Loose Teeth
  □ Clenching / Grinding
  □ Facial Pain (nonspecific)
  □ Tender, Sensitive Teeth when chewing
  □ Difficulty Chewing
  □ Neck Pain
  □ Posture Problems
  □ Tingling of Fingertips
  □ Hot or Cold Sensitivity
  □ Nervousness / Insomnia

Many of the above symptoms can be caused by a “bad bite”
(Malocclusion). If the quality of your life is affected by any of the
above symptoms, there are treatment options available to help stop
the suffering.

Would you like to explore these options?
  □ YES
  □ NO

								
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