Feel free to copy the form below.

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1. Can you localize the pain?  ______________________________
2. ​When did it start?   _____________________________________
3. When does it hurt?  _____________________________________
4. How long does the pain last?  ___________________________
5. How frequent is the pain?  ______________________________
6. Describe the pain.  Is it a sharp pain, dull ache or a throbbing pain?  ___________________________________________________
7. How intense is the pain of a scale of 1 - 10  with 10 being the worst?  __________________________________________________
8. Does the pain seem to get worse when you lie down?  ____
9. What causes the pain - hot, cold, sweets, pressure?  ______
10. Does hot or cold relieve the pain?  _______________________
11. Does it hurt when you touch your tooth or bite down?  ___
12. Does it feel like there is any swelling?  ____________________
13. Is there any bleeding or pus in the area?  _________________
14. Does the pain feel like it is in your jaw joint (TMJ)?  ________
15. Is it hard to open or close your mouth?  ___________________
16. Do the muscles of your face, head or neck seem sore or tender?  _________________________________________________
17. Do you have a headache or get headaches?  _____________
18. Does you jaw ever make a clicking or popping sound?  ___
19. Does your jaw ever seem to get stuck?  ___________________
20. Have you taken anything or done anything to try to get rid of the pain?   _______________________________________________