TMJ/MPD SCREENING QUESTIONNAIRE

This is a list of signs and symptoms commonly associated with temporomandibular joint disorder (TMJD) and/or myofascial pain dysfunction (MPD).

Please complete this checklist as it will help identify if you have any evidence of TMJ or MPD. You can print a copy and bring it with you at your first appointment.

Print .pdf version of questionnaire by click here

Print. Excel version of questionnaire by clicking here

 

 

TMJ & Orofacial Pain Treatment Centers of Wisconsin Central Center • 2626 N. 76th Street, Suite #101, Wauwatosa, WI 53213 • 414-476-9400 Waukesha Center • 2727 N. Grandview Boulevard, Suite #100, Waukesha, WI 53188 • 262-547-9422 Kenosha/Racine Center • 3500 Meachem, Racine, WI 53405 • 262-598-9901 Northeast Center • 200 W. Silver Spring Drive, Suite #310, Milwaukee, WI 53217 • 414-962-3100 Appleton/Green Bay Center • W3132 Van Roy Road, Appleton, WI 54915 • 920-882-1710