Campbell Ortho

History Form for Patient with Temporomandibular Disorder

We would like to thank you for referring clients to our office. In an effort to provide the best service, we ask you to fill out this form as completely as possible. Thank you for your cooperation.

Patient Information

Dr. Mr. Mrs. Miss Ms.

Major Reason for Current Evaluation

General History

Are you currently under the care of a physician or have you been in the last year?
On a scale from 0 to 10. Zero being Poor and Ten being Excellent;
On a scale from 0 to 10. Zero being Poor and Ten being Excellent;
Have you ever had any major dental treatment in the last two years?
What type of Treatment did you receive?: Orthodontics Periodontics Restorative

Facial Injury/Trauma History?

TMD Treatment History

Have you ever been examined for a TMD problem before?
What was the duration of the problem?
Is this a new problem
Have you ever had physical
therapy for TMD
Have you ever received treatment for jaw problems?
What was the treatment: Medication Physical Therapy Counseling

Current Medications or Appliances

Frequency of TMD pain:
Is there a pattern related to the pain occurrence?
Are you aware of anything that makes your pain worse?
Does your jaw make noise?
Right Jaw :
Left Jaw :
Does your Jaw lock open?
Has your jaw ever locked partially closed?
Have dental appliances been prescribed?
Are these appliances effective?

Current Stress Factors

Habit History

Do you clench your teeth together under stress?
Do you grind or clench your teeth at night?
Do you sleep with an unusual head position?
Are you aware of any habits or activities that may aggravate this condition?


Head Pain, Headaches, Facial Pain

Eye Pain or Ear Orbital Problems

Mouth, Face, Cheek & Chin Problems

Teeth and Gum Problems

Jaw & Jaw Joint (TMD) Problems

Pain, Ear Problems, Postural Imbalances

Throat Problems


Neck and Shoulder Pain

Other Pain


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