ClinicianName

Address

TMJSCALE

TM

Thisquestionnaireisdesignedtohelpyourdoctorevaluateyourproblem.Pleaseanswerall
questionsashonestlyaspossible.Useadark#2leadpencil.Markanswersclearly,erasing
completelyanychanges.Makenomarksoutsideanswerspaces. Donotskipany
questions,evenifyouarenotabsolutelysure.(MarkingExample:[] [] )
Initials:_________

FileNo.(filledinbyclinician)__________________

TodaysDate___/___/___

Age_____

MaritalStatus [1] Single

[2] Married
(markone)

[4] Divorced
[5] Widowed
[6] Remarried

[3] Separated

Sex(markone)
Ethnic/Racial
Group
(markone)

[1] Male

[2] Female

[1] Black
[4] White
[2] Hispanic [5] Other
[3] Oriental

NumberofSchoolYears(markone) [1] [2] [3] [4] [5] [6] [7] [8][9][10]

[11][12][13][14][15][16][17][18][19][20+]

[1] None
[3] 15Months
[5] 12Years
[7] 610Years
ProblemLength
[2]
LessThan1Month
[4]
611Months
[6]
35Years
[8] 10+Years
(markone)
1. Thisquestionshouldonlybeansweredifyouhaveupperandlowerfrontteethorarewearinga
replacementforthem.Openyourmouthaswideaspossibleandpositionyourhandasshowninthe
diagrambelow.Placeasmanyfingersaspossiblebetweenyourupperandlowerfrontteeth.Now
markonenumber belowindicatingthenumberoffingers.

(markone)
lessthan1finger. [0]
atleast1finger. [1]
atleast2fingers [2]
atleast3fingers [3]
atleast4fingers [4]
Forquestions#28below,locateeachareaonyourface(exceptF)usingthelettereddiagram.Press
eachareafirmlyonbothsidesofyourface. Markthenumber thatindicatesthemaximumamount
ofpainyoufeel.
nopain 0
slightpain 1
moderatepain 2
quiteabitofpain 3
extremepain 4
(markone)
2.
3.
4.
5.
6.
7.
8.

Pressingmytemples(Aondiagram).......
Pressingmyjawjoints(Bondiagram)
Pressingmyjawmuscles(Condiagram)
Pressingthemusclesunderthesidesofmyjaw(Dondiagram).
Pressinginmyears(Eondiagram).........
Pressingthebackofmyneck(Gondiagram).
Pressingthesidesofmyneck(Hondiagram)..
S.R.LevittM.D.,Ph.D.,T.F.Lundeen,D.M.D.,M.W.McKinney,Ph.D.
Copyright1984,1987PainResourceCenter,Inc.AllRightsReserved.

[0][1][2][3][4]
[0][1][2][3][4]
[0][1][2][3][4]
[0][1][2][3][4]
[0][1][2][3][4]
[0][1][2][3][4]
[0][1][2][3][4]

Markthenumber whichbestdescribeshowmuchofthetimeeachstatementbelowappliestoyou,
usingthefollowingkey:
noneofthetime 0
alittleofthetime 1
amoderateamountoftime 2
quiteabitoftime 3
all ofthetime 4
(markone)
9.
10.
11.
12.

Justalighttouchonmyfacecausesshocklikepain...
MyjawmustclickorpopbeforeIcanopenitwide
Myjawopensallthewaywithoutanysidewaysmovements..
Myjawlocksopen...

[0][1][2][3][4]

13.
14.
15.
16.
17.
18.

Ihaveheadacheswhichbeginafterseeingflashesoflightordarkspots
Myjawmoveseasily
Ihavehealthproblemswhichhaven'trespondedtotreatment.....
Ihavepaininmyjawjoint(s)(Bonthediagram)...
Myjawtireseasilywhenchewing...
Ihaveheadacheswhicharemadeworsebybrightlight..........

[0][1][2][3][4]

19.
20.
21.
22.
23.
24.
25.
26.
27.
28.

IthurtsmyteethwhenIbite.
Ihavemuscleorjointpaininareasotherthanmyheadorneck.
Icanmovemyjawmoretoonesidethantheother.
Ifeeltenseandworried
Ihavedrainagefrommyear(s)
Ifeelsadanddepressed
Iclenchmyteeth..
Mybitefeelscomfortable
IhavejawpainwhichgetsworsethemoreImovemyjaw
Itisdifficulttofindacomfortablepositionformyjaw...

[0][1][2][3][4]

29.
30.
31.
32.
33.
34.
35.
36.
37.
38.

Ihavepaininmyear(s)(Eondiagram)...
Ihavesinusproblems...
WhenIbitedownnormally,myfrontteethtouch...
Duringmylife,I'vehadmanydifferentpainfuldisorders...
Ihavefacialpainwhichcomesonsuddenlylikeelectricshocks
Icanopenmymouthasfaraspossiblewithoutpain...
Ihavepaininorbehindmyeye(s)...
Myjawmakesagratingorgrindingnoisewhenitopensandcloses..
Ithinkmybiteisoff.
Ihavepainwhichgetsworsewithstressortension

[0][1][2][3][4]

[0][1][2][3][4]
[0][1][2][3][4]
[0][1][2][3][4]

[0][1][2][3][4]
[0][1][2][3][4]
[0][1][2][3][4]
[0][1][2][3][4]
[0][1][2][3][4]

[0][1][2][3][4]
[0][1][2][3][4]
[0][1][2][3][4]
[0][1][2][3][4]
[0][1][2][3][4]
[0][1][2][3][4]
[0][1][2][3][4]
[0][1][2][3][4]
[0][1][2][3][4]

[0][1][2][3][4]
[0][1][2][3][4]
[0][1][2][3][4]
[0][1][2][3][4]
[0][1][2][3][4]
[0][1][2][3][4]
[0][1][2][3][4]
[0][1][2][3][4]
[0][1][2][3][4]

Markthenumber whichbestdescribeshowmuchofthetimeeachstatementbelowappliestoyou,
usingthefollowingkey:
noneofthetime 0
alittleofthetime 1
amoderateamountoftime 2
quiteabitoftime 3
allofthetime 4
(markone)
39.
40.
41.
42.

MyjawclicksorpopswhenIchew.
Icanbitedownhardwithoutpaininmyjaw...
Onepainfulproblemisfollowedbyanother
Ihavejawpainwhichmakesmefeelsickandfeverish..

[0][1][2][3][4]

43.
44.
45.
46.
47.
48.

Igrindmyteethduringtheday
Ihavenumbareasonmyface..
Iusenervepills,sleepingpills,oralcoholforrelief
Icanmovemyjawsmoothly...
Icanchewwithoutbumpingmyteethunexpectedly...
Ihaveafeelingofpinsandneedlesonmyface...

[0][1][2][3][4]

49.
50.
51.
52.
53.
54.
55.
56.
57.
58.

Ihavepaininmyjawmuscles(Condiagram)
Ihavepaininthebackofmyneck(Gondiagram).
Overtheyears,I'vebeenunderalotofstress..
Myjawtwitchesorjerksuncontrollably..
WhenIbitedownnormally,mybackteethtouch...
Thewaymyfrontteethfitseemstobechanging
Alighttouchononesideofmyfacecausesshocklikepainontheother..
Ihavearinginginmyear(s)
Ihavepainwhichgetsworsewithcertainpeopleorsituations...
Ihavepainintheside(s)ofmyneck(Hondiagram)..

[0][1][2][3][4]

59.
60.
61.
62.
63.
64.
65.
66.
67.
68.

Ihaveasteadypainacrossmyforehead..
Ihavemanychangingpains.
Ifeelangry...
OtherpeoplenoticenoisefrommyjawwhenIchew..
IcanchewfoodaswellasIusedto.
Ihavehealthproblemswhichseemtobegettingworse..
Ihavepaininthemusclesundermyjaw(Dondiagram)
Ihavepaininmytemple(s)(Aondiagram)
Ifeelanxious
IcanopenmymouthaswideasIusedto

[0][1][2][3][4]

[0][1][2][3][4]
[0][1][2][3][4]
[0][1][2][3][4]

[0][1][2][3][4]
[0][1][2][3][4]
[0][1][2][3][4]
[0][1][2][3][4]
[0][1][2][3][4]

[0][1][2][3][4]
[0][1][2][3][4]
[0][1][2][3][4]
[0][1][2][3][4]
[0][1][2][3][4]
[0][1][2][3][4]
[0][1][2][3][4]
[0][1][2][3][4]
[0][1][2][3][4]

[0][1][2][3][4]
[0][1][2][3][4]
[0][1][2][3][4]
[0][1][2][3][4]
[0][1][2][3][4]
[0][1][2][3][4]
[0][1][2][3][4]
[0][1][2][3][4]
[0][1][2][3][4]

Markthenumber whichbestdescribeshowmuchofthetimeeachstatementbelowappliestoyou,
usingthefollowingkey:
noneofthetime 0
alittleofthetime 1
amoderateamountoftime 2
quiteabitoftime 3
allofthetime 4
(markone)
69.
70.
71.
72.

Thewaymybackteethfitseemstobechanging.
Isleepwell...
IhaveheadorfacialpainwhichgetsworsewhenIbendover
WhenItouchonesideofmyface,theothersidegetsnumb...

[0][1][2][3][4]

73.
74.
75.
76.
77.
78.

Myjawgetsstuckandwon'topenalltheway.
Theonlyrealproblemsinmylifeareproblemswithmyphysicalhealth...
I'vehadconflictingdoctors'opinionsabouthealthproblems..
Icanmovemyjawinanydirectionwithoutpain
Ihavefacialpainwhichgetsworseincoldweather
Ifeelfrustrated.

[0][1][2][3][4]

79.
80.
81.
82.
83.
84.
85.
86.
87.
88.

Ihaveastuffynose...
RecentlyI'vebeenunderalotofstress
Ihaveheadacheswhichmakemefeelsicktomystomach.
Icantakebigbitesof thingslikeapples..
Ihaveworkorfamilypressures...
Ihavepainandstiffnessinmyfingerjoints
Mybackteethfeelliketheyfitproperly..
IbelieveIhaveanincurableprobleminspiteofreassurancebydoctors
Inthemorningmyteetharesoreandmyjawistired..
Myearsfeelblockedorstoppedup.....

[0][1][2][3][4]

89.
90.
91.
92.
93.
94.
95.
96.
97.

Ihavemanyhealthproblems...
Myjawmovesjustasfarforwardasitusedto
Ihavedifficultyswallowing.
Ihavepainbehindmyear(s)(Fondiagram)...
Ihavefacialpainwhenotherjointsarealsosore
Ihavenervousproblems..
Ihavethrobbingheadaches..
Ifeeldizzy
Iconsidermyselftobeasicklyperson

[0][1][2][3][4]

[0][1][2][3][4]
[0][1][2][3][4]
[0][1][2][3][4]

[0][1][2][3][4]
[0][1][2][3][4]
[0][1][2][3][4]
[0][1][2][3][4]
[0][1][2][3][4]

[0][1][2][3][4]
[0][1][2][3][4]
[0][1][2][3][4]
[0][1][2][3][4]
[0][1][2][3][4]
[0][1][2][3][4]
[0][1][2][3][4]
[0][1][2][3][4]
[0][1][2][3][4]

[0][1][2][3][4]
[0][1][2][3][4]
[0][1][2][3][4]
[0][1][2][3][4]
[0][1][2][3][4]
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