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TMJ Pain/Disorder Intake Form
Please complete this form prior to your appointment with us.
First Name
Last Name
Date Of Birth
Phone
Email
Were you referred to us by another provider?
Referring Provider
Referring Provider's Phone Number
Reason For Referral
Do you have pain or dysfunction in your jaw, face, temples, ears, or neck?
Have you previously been treated for TMJ pain?
If you have previously been treated for TMJ pain, please describe what treatment was done.
Is the pain due to a primary dental cause? (Caries, periodontal disease, abscess, recent dental work)
How long have you had these symptoms?
How have these symptoms impacted daily life?
Where do you experience pain? (Choose all that apply)
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