Patient: TMJ Symptoms Sheet

Eyes

Pain around eyes?

N R S U A

Blurred vision?

N R S U A

Pressure behind eyes?

N R S U A

Pain behind eyes?

N R S U A

Light sensitivity?

N R S U A

Watering eyes?

N R S U A

Head and/or Face

Forehead pain?

N R S U A

Temple pain?

N R S U A

Facial muscle cramps?

N R S U A

Facial pain?

N R S U A

Headaches?

N R S U A

Pain in back of head?

N R S U A

Pain in scalp or hair?

N R S U A

Jaw Point Pain

Pain right side?

N R S U A

Pain left side?

N R S U A

Jaw sticks open/closed?

N R S U A

Unintentional biting of cheek, lip or tongue?

N R S U A

TMJ clicking/popping?

N R S U A

TMJ grating/cracking?

N R S U A

Uncontrolled jaw or tongue movements?

N R S U A

Self-Imaging and Coping

Negative feelings of self?

N R S U A

Fear of negative reactions of others?

N R S U A

Changes in social roles?

N R S U A

Insomnia?

N R S U A

Anxiety?

N R S U A

Depression?

N R S U A

Fatigue?

N R S U A

Rejection by loved ones?

N R S U A