| Do you get an unusual amount of headaches? |
Yes |
No |
| Do you have a grating, clicking or popping sound in either or both jaw joints, when you chew or open and close your mouth? |
Yes |
No |
| Do you have pain or soreness in any of the following areas: jaw joints, upper jaw, lower jaw, side of neck, back of head, forehead, behind the eyes or temples? |
Yes |
No |
| Do you have sensations of stuffiness, pressure or blockage in your ears? Is there excessive wax buildup? |
Yes |
No |
| Do you ever have ringing, roaring, hissing or buzzing sounds in your ears? |
Yes |
No |
| Do you ever feel dizzy or faint? |
Yes |
No |
| Do your fingers, hands or arms sometimes tingle or go numb? |
Yes |
No |
| Are you tired all the time, fatigue easily or consider yourself
chronically fatigued?
|
Yes |
No |
| Are there imprints of your teeth on the sides of your tongue? |
Yes |
No |
| Does your tongue go between your teeth when you swallow? |
Yes |
No |
| Do you have difficulty in chewing your food? |
Yes |
No |
| Do you have any missing back teeth? |
Yes |
No |
| Do you clench your teeth during the day or at night? |
Yes |
No |
| Do you grind your teeth at night? (Ask your family.) |
Yes |
No |
| Do you ever awaken with a headache? |
Yes |
No |
| Have you ever had a whiplash injury? |
Yes |
No |
| Have you ever experienced a blow to the chin, face or head? |
Yes |
No |
| Have you reached the point where drugs no longer relieve your symptoms? |
Yes |
No |
| Does chewing gum worsen your symptoms? |
Yes |
No |
| Is it painful to stick your "pinky" fingers into your ears with your mouth open wide and then close your mouth while pressing forward with your "pinky" fingers? |
Yes |
No |
| Does your jaw slide to the left or right when you open wide?
(Look in a mirror.)
|
Yes |
No |
| Are you unable to insert your first three fingers vertically into your mouth when it is open wide? |
Yes |
No |
| Is your face crooked and not symmetrical? |
Yes |
No |
