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Appendix E

Screening Questionnaire

Subject # ___________________________________Date

Name: ____________________________________Sex:_______________
Address: ___________________________________Race:______________
Age: _____________
Phone #: e-mail:

1. Have you had difficulty or pain, or both, when opening your mouth as for instance when yawning in the
last 12 months?
YES NO

2. Has your jaw gotten 'stuck', 'locked' or otherwise 'gone out' in the last 12

months? YES NO

3. Do you have difficulty or pain, or both when chewing, talking, or using your jaw in the last 12 months?
YES NO

3a. Is there tenderness in the joint? YES NO

3b. Is there tenderness in the jaw muscle? YES NO

4. Does you jaw joint ever make a 'popping', 'clicking' or 'grinding' noise when chewing, talking or using
your jaw?
YES NO

5. Is there tenderness, weakness or fatigue in your jaw?

YES NO

6. Have you had pain in or about the ears, temple or cheeks in the last 12 months?

YES NO

7. Does your bite feel uncomfortable or unusual?

YES NO
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8. Please answer the following questions about the nature of your pain:
a).When did you last experience this pain?____________________________________________
b)._______________________________________________________How frequent is the pain?
c).Does the pain occur on the right or left side of your face?______________________________
d)._________________________________________________How long have you had the pain?
e).Does the pain interfere with eating, chewing or swallowing? ___________________________
f). Does the pain limit how wide you can open your mouth?_________________________
g).______________________Does the pain limit your ability to move your jaw from side to side?

8. Do you have frequent headaches?

YES NO
a). Which of the following best describes the nature of your
headaches. TENSION MIGRAINE SINUS OTHER

9. Have you ever experienced any other persistent pain problem?

YES NO a). If yes briefly explain: ______________________________________

10. Have you ever had an injury to your head, neck or jaw?
YES NO a) If yes briefly describe: _____________________________________

11. Have you ever been diagnosed with arthritis or other painful
disorder of the joint? YES NO

12. Have you previously been treated for a jaw problem?

YES NO

a). In the last 12 months? YES NO

13. Are you currently taking any prescription medication?

YES NO a). If yes what type? ____________________

0. Do you suffer with any neuromuscular or degenerative joint disease?

YES NO

1. Have you ever been treated for a psychological problem?

YES NO

a). If yes what diagnosis were you given (if any)? ________________________

2. Are you currently pregnant?

YES NO

3. Have you had any dental work done in the last two weeks?
YES NO
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Appendix F

Weekly Facial Pain Diary

We would like you to rate the intensity of your facial pain four times a day using the
structured diary below. Please use the following scale to rate the intensity of your facial
pain during each time period.

0 = no facial pain
= only aware of facial pain when attention is devoted to it
2 = mild facial pain, could be ignored at times
3 = facial pain is painful, but can still do my job/go to classes, etc.
4 = very severe facial pain, difficult to concentrate, can only do undemanding tasks
5 = intense, incapacitating facial pain

Monday Tuesday Wednesday Thursday Friday Saturday Sunday

Time of
Day (date) (date) (date) (date) (date) (date) (date)

Awake-
11:00am
11:00am-
3:00pm
3:00pm-
7:00pm
7:00pm-
bedtime

Medications: Each time you rate your facial pain also indicate any medicine you took
since the last rating. Include the name and amount of the medicine. You can make
your own table of abbreviations and dosages to make filling in the chart easier.

For example:

T = Tylenol (regular strength- 500mgl___________

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Appendix G

Oral Habits Questionnaire

Listed below are a number of behaviors involving the mouth, the lower part of the face,
and various motor habits that people sometimes engage in to varying degrees. This helps
us understand more about what types of behavior you engage in.
Please answer the following questions by circling the number that best indicates the
degree to which you engage in the specified behavior.
Almost
Never Always
1........................................................... I clench my teeth 1 2 3 4 5 6
...................................................7 8 9 10

2........................................................... I smoke a pipe 1 2 3 4 5 6 7

...................................................8 9 10

3..........................................................I
bite my lips .1 2 3 4 5 6 7
..................................................8 9 10

4........................................................... [chew gum1 2 3 4 5 6 7 8

...................................................9 10

5. I play a musical instrument that requires

extensive use of my lips or chin.. 1 2 3 4 5 6 7 8 9 10

6. I hold the telephone receiver between

my chin and shoulder................. 1 2 3 4 5 6 7 8 9 10

0........................................................... I bite the sides of my mouth 1 2 3 4 5

...................................................6 7 8 9 10

7........................................................... I
chew on my tongue 1 2 3 4 5 6
...................................................7 8 9 10

8........................................................... 1 chew on objects like pens or 1 2 3 4

...................................................5 6 7 8 9 10
Pencils.

0.......................................................................I chew on toothpicks 1 2 3 4 5

.............................................................6 7 8 9 10
II. I thrust my jaw forward.............. 1 2 3 4 5 6 7 8 9 10

12. I move my jaw from side to side.12 3

4 5 6 7 8 9 10

13......................................................... I
rest my head on my hands 1 2 3 4 5
...................................................6 7 8 9 10
while sitting.
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Almost
Never Always
14. I bite my nails............................. I 2 3 4 5 6 7 8 9 10

15. I smoke cigarettes...................... 1 2 3 4 5 6 7 8 9 10

16. I chew tobacco........................... 1 2 3 4 5 6 7 8 9 10

17. I wet my lips with my tongue... 1 2 3 4 5 6 7 8 9 10

18. I sleep on my stomach ................1 2 3 4 5 6 7 8 9 10

19. I yawn......................................... 1 2 3 4 5 6 7 8 9 10

20. I grind my teeth at night............. 1 2 3 4 5 6 7 8 9 10

21. I move around while sitting ....... 1 2 3 4 5 6 7 8 9 10

0. I shift my position while .......... 1 2 3 4 5 6 7 8 9 10

standing.

1. I move my feet or legs while..... 1 2 3 4 5 6 7 8 9 10

sitting.

22. I move my feet or legs while

standing in one position............ 1 2 3 4 5 6 7 8 9 10

23. I pace ............................................1 2 3 4 5 6 7 8 9 10

24. i touch my face or my hair............ 1 2 3 4 5 6 7 8 9 10

2. I tap with my fingers or other.... 1 2 3 4 5 6 7 8 9 10

objects.

25. I squint my eyes............................ 1 2 3 4 5 6 7 8 9 10