St. John's, NL
55 White Rose Drive, Suite 201
St. John's, Newfoundland A1A 0L2
Mon–Fri: 8:00 AM–3:00 PM
3a. Please indicate areas of pain by drawing on the figures below:
Select a brush color:
3b. Please indicate areas of pain by drawing on the figures below:
3c. Please indicate areas of pain by drawing on the figures below:
9. Please indicate how you would describe this pain (Check all that apply):
10. Please check all accompanying signs and symptoms:
11. Is there a history of trauma?
12. Has your condition interfered with any aspects of your life?
12b. If yes, please check all that apply:
13. Does the TMD pain wake you during sleep?
15. Have you ever had or currently have any of the following medical conditions? (Please check each one that applies)
16. Do you have caffeine in your diet?