Please read:
Please check the one statement that best pertains to you (not necessarily exactly) in each of the following categories.
Section 1- Communication (talking)
I can talk as much as I want without pain, fatigue or discomfort.
I talk as much as I want, but it causes some pain, fatigue and/or discomfort.
I can't talk as much as I want because of pain, fatigue and/or discomfort.
I can't talk much at all because of pain, fatigue and/or discomfort.
Pain prevents me from talking at all.
Section 2- Normal living activities (brushing teeth/flossing).
I am able to care for my teeth and gums in a normal fashion without restriction, and without pain, fatigue or discomfort.
I am able to care for all my teeth and gums, but I must be slow and careful, otherwise pain/discomfort, jaw tiredness results.
I do manage to care for my teeth and gums in a normal fashion, but it usually causes some pain/discomfort, jaw tiredness no matter how slow and careful I am.
I am unable to properly clean all my teeth and gums because of restricted opening and/or pain.
I am unable to care for most of my teeth and gums because of restricted opening and/or pain.
Section 3- Normal living activities (eating, chewing)
I can eat and chew as much of anything I want without pain/discomfort or jaw tiredness.
I can eat and chew most anything I want, but it sometimes causes pain/discomfort and/or jaw tiredness.
I can't eat much of anything I want, because it often causes pain/discomfort, jaw tiredness or because of restricted opening.
I must eat only soft foods (consistency of scrambled eggs or less) because of pain/discomfort, jaw fatigue and/or restricted opening.
I must stay on a liquid diet because of pain and/or restricted opening.
Section 4- Social/recreational activities(singing, playing musical instruments, cheering, laughing, social activities, playing amateur sports/hobbies, and recreation, etc).
I am enjoying a normal social life and/or recreational activities without restriction.
I participate in normal social life and/or recreational activities but pain/discomfort is increased.
The presence of pain and/or fear of likely aggravation only limits the more energetic components of my social life(sports, exercising, dancing, playing musical instrument, singing).
I have restrictions socially, as I can't even sing, shout, cheer,play and/or laugh expressively because of increased pain/discomfort.
I have practically no social life because of pain
Section 5- Non-specialized jaw activities(yawning, mouth opening and opening my mouth wide).
I can yawn in a normal fashion, painlessly.
I can yawn and open my mouth fully wide open, but sometimes there is discomfort.
I can yawn and open my mouth wide in a normal fashion, but it almost always causes discomfort.
Yawning and opening my mouth wide are somewhat restricted by pain.
I cannot yawn or open my mouth more than two finger widths(2.8-3.2 cm) or, if I can, it always causes greater than moderate pain.
Section 6- Sexual function(including kissing, hugging and any and all sexual activities to which you are accustomed).
I am able to engage in all my customary sexual activities and expressions without limitation and/or causing headache, face or jaw pain.
I am able to engage in all my customary sexual activities and expression, but it sometimes causes some headache, face, or jaw pain, or jaw fatigue.
I am able to engage in all my customary sexual activities and expression, but it usually causes enough headache, face or jaw pain to markedly interfere with my enjoyment, willingness and satisfaction.
I must limit my customary sexual expression and activities because of headache, face or jaw pain or limited mouth opening.
I abstain from almost all sexual activities and expression because of the head, face or jaw pain it causes.
Section 7- Sleep (restful, nocturnal sleep pattern).
I sleep well in a normal fashion without any pain medication, relaxants or sleeping pills.
I sleep well with the use of pain pills, anti-inflammatory medication or medicinal sleeping aides.
I fail to realize 6 hours restful sleep even with the use of pills.
I fail to realize 4 hours restful sleep even with the use of pills.
I fail to realize 2 hours restful sleep even with the use of pills.
Section 8- Effects of any form of treatment, including, but not limited to, medications, in-office therapy, treatment, oral orthotics (eg, splints, mouthpieces), ice/heath, etc.
I do not need to use treatment of any type in order to control or tolerate headache, face or jaw pain and discomfort.
I can completely control my pain with some form of treatment.
I get partial, but significant, relief through some form of treatment.
I don't get "a lot of" relief from any form of treatment.
There is no form of treatment that helps enough to make me want to continue.
Section 9- Tinnitus, or ringing in the ear(s)
I do not experience ringing in my ear(s)
I experience ringing in my ear(s) somewhat, but it does not interfere with my sleep and/or my ability to perform my daily activities.
I experience ringing in my ear(s) and it interferes with my sleep and/or daily activities, but I can accomplish set goals and I can get an acceptable amount of sleep.
I experience ringing in my ear(s) and it causes a marked impairment in the performance of my daily activities and/or results in an unacceptable loss of sleep.
I experience ringing in my ear(s) and it is incapacitating an/or forces me to use a masking device to get any sleep.
Section 10- Dizziness (lightheaded, spinning and/or balance disturbance).
I do not experience dizziness.
I experience dizziness, but it does not interfere with my daily activities.
I experience dizziness which interferes somewhat with my daily activities, but I can accomplish my set goals.
I experience dizziness, which causes a marked impairment in the performance of my daily activities.
I experience dizziness, which is incapacitating.