| Do you have difficulty, pain, or both when opening your mouth,
for instance, when yawning? |
Yes |
No |
| Does your jaw get "stuck," "locked," or
"go out"? |
Yes |
No |
| Do you have difficulty, pain, or both when chewing, talking,
or using your jaws? |
Yes |
No |
| Are you aware of noises in your jaw joints? |
Yes |
No |
| Do you have pain in or about the ears, temples or cheeks? |
Yes |
No |
| Do you have frequent headaches and/or neckaches? |
Yes |
No |
| Have you ever had an accident, fall or injury? |
Yes |
No |
| Are you aware of any recent changes in your bite? |
Yes |
No |
| Have you previously been treated for a jaw-joint problem? |
Yes |
No |
| Do you clench or grind your teeth? |
Yes |
No |
| Do you have a stressful situation at work? |
Yes |
No |
| Do you have a stressful situation at home? |
Yes |
No |
| Do you have a decreased appetite? |
Yes |
No |
| Do you feel low in energy or slowed down? |
Yes |
No |
| Do you feel easily annoyed or irritated? |
Yes |
No |
| Do you consider yourself to be a perfectionist? |
Yes |
No |
| Do you feel little interest in doing things? |
Yes |
No |
| Do you feel lonely even with people? |
Yes |
No |
| Do you feel hopeless about the future? |
Yes |
No |
| Do you have a decreased desire for social activities? |
Yes |
No |
| Do you have a loss of interest in sex? |
Yes |
No |
| Have you ever seen a psychiatrist, psychologist or social
worker? |
Yes |
No |
| Do you have a morning headache? |
Yes |
No |
| Do you sleep poorly at night? |
Yes |
No |
| Do you have trouble falling asleep? |
Yes |
No |
| Do you take medication/alcohol to fall asleep? |
Yes |
No |
| Do you wake up during the night? |
Yes |
No |
| Do you snore while sleeping? |
Yes |
No |
| Do you gasp for air in your sleep? |
Yes |
No |
| Do you mouth breathe while sleeping? |
Yes |
No |
| Do you clench or grind your teeth at night? |
Yes |
No |
| Do you thrash your legs in your sleep? |
Yes |
No |
| Do you feel exhausted upon arising? |
Yes |
No |
| Do you wake up too early in the morning? |
Yes |
No |
| Do you have stiff muscles in the morning? |
Yes |
No |
| Do you have difficulty staying awake during the day? |
Yes |
No |
| Do you feel tired during the day? |
Yes |
No |
| Do you read or watch TV in bed? |
Yes |
No |
| Do you use two pillows? |
Yes |
No |
| Do you sleep on your stomach? |
Yes |
No |
