| 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 |
