TMJD Assessment
Patient Name:
Patient Number:
Date:
Main concern:
History of complaint:
Duration of symptoms:
Frequency of symptoms:
Pain at any particular time
of the day or night?
Morning?
Night?
Any headaches?
How well are you
sleeping?
Is it disturbed?
Any jaw clicking?
Painful?
How often?
Both Sides?
Crepitus?
Teeth grinding:
At night?
In the day?
Teeth clenching:
At night?
In the day?
Is your job stressful?
Any snoring?
Have you had orthodontic
treatment in the past?
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TMJD Assessment
Have you had any
previous problems
with your ears such as
leakage, ear infections
or tinnitus?
Methods of TMJ
management employed
to date (SOC,
exercises, etc.)?
Evidence of any
stress in life?
Do you find you are
restricted in what you can
eat because of your TMD
pain? Which foods?
MEDICAL HISTORY
Medication
Prescribed:
Medication Self
Administered:
Allergies:
Medical Conditions:
Smoker:
Alcohol:
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TMJD Assessment
Patient Oral Health Impact Profile-2 2 Questionnaire
1. Do you have problems chewing any foods?
Never Hardly ever Occasionally
Fairly often
Very often
2. Do you find it uncomfortable to eat any foods?
Never Hardly ever Occasionally Fairly often
Very often
3. Do you find you have to avoid eating some foods?
Never Hardly ever Occasionally Fairly often
Very often
4. Does jaw pain interrupt meals?
Never Hardly ever Occasionally
Fairly often
Very often
5. Have you had difficulties in opening and closing your mouth?
Never Hardly ever Occasionally Fairly often
Very often
6. Have you had any painful aching in your mouth or jaw?
Never Hardly ever Occasionally Fairly often
Very often
7. Have you had a sore jaw?
Never Hardly ever Occasionally
Fairly often
Very often
8. Do you suffer with headaches?
Never Hardly ever Occasionally
Fairly often
Very often
9. Have you felt speech was painful because of problems with your teeth, mouth,
dentures or jaws?
Never Hardly ever Occasionally Fairly often Very often
10. Are you worried by dental problems?
Never Hardly ever Occasionally
Fairly often
Very often
11. Are you self-conscious about your jaw?
Never Hardly ever Occasionally
Fairly often
Very often
12. Have jaw problems made you miserable?
Never Hardly ever Occasionally
Fairly often
Very often
13. Have you felt tense because of jaw problems?
Never Hardly ever Occasionally Fairly often
Very often
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TMJD Assessment
14. Has your sleep been interrupted?
Never Hardly ever Occasionally
Fairly often
Very often
15. Have you been upset because of your jaw/facial discomfort?
Never Hardly ever Occasionally Fairly often
Very often
16. Do you find it difficult to relax?
Never Hardly ever Occasionally
Fairly often
Very often
17. Do you feel depressed?
Never Hardly ever Occasionally
Fairly often
Very often
18. Has your concentration been affected?
Never Hardly ever Occasionally
Fairly often
Very often
19. Do you become a bit irritable with other people?
Never Hardly ever Occasionally Fairly often
Very often
20. Do you have difficulty doing your usual jobs?
Never Hardly ever Occasionally Fairly often
Very often
21. Do you find life in general less satisfying?
Never Hardly ever Occasionally
Fairly often
Very often
22. Are you unable to work to your full capacity because of jaw/facial pain?
Never Hardly ever Occasionally Fairly often Very often
On the line below, please mark a point to identify where your pain has
been on average over the last week:
No Pain
Worst pain imaginable
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TMJD Assessment
Please put a mark on any area that is painful or tense
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TMJD Assessment
l feel tense or ‘wound up’:
Most of the time
3
A lot of the time
2
From time to time, occasionally 1
Not at all
0
I still enjoy the things I used to enjoy:
Definitely as much
0
Not quite so much
1
Only a little
2
Hardly at all
3
I get a frightened feeling as if something awful is about to happen:
Very definitely and quite badly
Yes, but not too badly
A little, but it doesn’t worry me
Not at all
3
2
1
0
I can laugh and see the funny side of things:
As much as I always could
0
Not quite so much now
1
Definitely not so much now
2
Not at all
3
Worrying thoughts go through my mind:
A great deal of the time
3
A lot of the time
2
From time to time, but not too often
1
Only occasionally
0
I feel cheerful:
Not at all
3
Not often
2
Sometimes
1
Most of the time
0
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TMJD Assessment
I can sit at ease and feel relaxed:
0
1
2
3
Definitely
Usually
Not often
Not at all
l feel as if I am slowed down:
Nearly all the time
3
Very often
2
Sometimes
1
Not at all
0
I get a sort of frightened feeling like butterflies in the stomach:
0
1
2
3
Not at all
Occasionally
Quite often
Very often
I have lost interest in my appearance:
Definitely
3
l don’t take as much care as I should
2
I may not take quite as much care
1
I take just as much care as ever
0
I feel restless as I have to be on the move:
Very much indeed
3
Quite a lot
2
Not very much
1
Not at all
0
I look forward with enjoyment to things:
As much as I ever did
0
Rather less than I used to
1
Definitely less than I used to
2
Hardly at all
3
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TMJD Assessment
I get sudden feelings of panic:
Very often indeed
3
Quite often
2
Not very often
1
Not at all
0
I can enjoy a good book or radio or TV programme:
Often
0
Sometimes
1
Not often
2
Very seldom
3
E/O Examination
MOUTH OPENING
At first open
mm
At stretch
mm
Mouth opening in mm
Pain?
Yes
No
• All data collected on this form will be kept confidential. The data collected will be used for the evaluation of the Cerezen device.
• Details of contraindications can be viewed at www.cerezen.eu or are available on request at any time from the prescribing dentist.
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TMJD Assessment
E/O Examination
MASSETERS
Enlarged or tender?
Yes
Palpation
of Masseter
No
TEMPORALIS
Enlarged or tender?
Yes
Palpation
of Temporalis
No
Lateral Pterygoids:
Tenderness?
Any clicking in the joints?
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Yes
No
Yes
No
TMJD Assessment
I/0 Examination:
Scalloping of the tongue?
Worn dentition?
Linea alba?
Multiple ‘chipped’ teeth
Radiographic assessment
Comments on TMJ’s,
caries, periodontal disease
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TMJD Assessment
First Visit - Cerezen Device
Date today:
In a few sentences below, please can you write what improvements you would
ideally like the Cerezen device to achieve?
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TMJD Assessment
Two Month Follow-Up - Cerezen Device
Date today:
Thank you for attending today’s follow-up appointment regarding the use of your
Cerezen device. Please can you write a few sentences below describing your
early thoughts on your experience of using the Cerezen device after one month.
Many thanks.
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TMJD Assessment
4 Month Follow-up - Cerezen device
Date today:
Please can you write a few sentences below describing your thoughts and
experiences of the Cerezen device so far.
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TMJD Assessment
6 Month Follow-up - Cerezen device
Date today:
Please can you write a few sentences below describing your experience of using
the Cerezen device over the last 6 months?
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