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