WILMINGTON ORTHODONTIC CENTER

TMJ form

 

Tell us about you.

Do you have clicking, popping or grating noise in your left jaw joint? *
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When did you first notice the noise? *
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Has the noise recently become more pronounced *
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When? *
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Do you have pain in or around the right jaw joint? *
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Do you have pain in or around the left jaw joint? *
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When did you first notice the pain? *
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Has the pain recently become more pronounced? *
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When? *
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Is the pain worse:
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Is the pain:

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Does the pain sometimes feel like it is in your ear? *
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Do you think this problem has affected your hearing? *
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Does your jaw problem interfere with your normal activities? *
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Are you taking or have you taken medication for this problem? *
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If yes, please list medication taken:
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Did anything occur which might be related to the onset of this problem? *
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Please describe:
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Do you have difficulty chewing? *
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because of:

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Do you have headaches? *
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How frequent? *
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Location? *
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Has your mouth ever locked open so you were unable to close it?

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Explain:
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Have you had problems opening your mouth wide? *
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Explain:
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Please indicate the time sequence in which you became aware of the following problems (1-4). Number only those problems which apply to you.
Pain
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Noise
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Limited opening
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Locking
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Other
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Which aspects of your problem concerns you the most?
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Are you clenching your teeth? *
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When? *
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Do you grind your teeth? *
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When? *
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Has there been a recent change in your lifestyle such as marital status, childbirth, change of employment, death in immediate family or othe stressful events? *
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Do you think nervous tension seems to affect this problem? *
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Explain:
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Have you had problems with other joints? *
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Have you had previous orthodontic treatment? *
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When? *
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Where? *
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Have you had recent dental treatment? *
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Explain:
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Have you had x-rays taken for this problem? *
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When? *
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Where? *
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Have you received previous treatment for this problem? *
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Testimonials

With so many great choices in the area for a good orthodontist, we searched and searched for the best fit and are so glad we found Dr. Pancko. The doctor is so wonderful, instantly giving us the feeling that our son is in good medical hands with a qualified and knowledgeable orthodontist.

Dave Marcus