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TMJ TRIAGE FORM

Please complete the form below. This information will help us schedule your Initial Assessment with the most appropriate practitioner for your case.

First and Last Name

Phone

Referring Doctor

What is your Primary Complaint?

Were you referred to a specific Practitioner?

Have you had surgery or trauma to the jaw, head, or face? If yes, please describe.

Please rate your pain on a scale from 0 - 10. (0 = none, 10 = unbearable)

Is your jaw locked or unable to open? * Required

Yes

Has your bite or the way your teeth come together changed? * Required

Yes

Is there visible swelling on your face? * Required

Yes

Do you experience sharp or burning pain? * Required

Yes

Do you feel pain in your teeth? * Required

Yes

Does pain wake you up at night? * Required

Yes

Do you experience numbness in your head or face? * Required

Yes

Do you experience nausea? * Required

Yes

Do you have difficulty speaking or swallowing? * Required

Yes

Do you experience dizziness or vertigo? * Required

Yes

Any additional information:

Thank you for submitting this form!

*Required Information

The Centre of Fitness, Health and Performance

1 St Clair Avenue East Suite #1001 (Tenth Floor) Toronto, Ontario - M4T 2V7

(416) 972-6279

clinic@cffhp.com

Mon - Fri 7:30 a.m - 7:00 p.m

Sat - 7:30 a.m - 7:00 p.m

Sun - Closed

Office Hours

Monday: 7:30 a.m. - 7 p.m.

Tuesday: 7:30 a.m. - 7 p.m.

Wednesday: 7:30 a.m. - 7 p.m.

Thursday: 7:30 a.m. - 7 p.m.

Friday: 7:30 a.m. - 7 p.m.

Saturday: 9 a.m. - 2 p.m.

Sunday: Closed

Contact Us

1 St Clair Avenue East

Suite #1001 (Tenth Floor)

Toronto, Ontario - M4T 2V7

Phone: (416) 972-6279

Fax: (416) 972-0351

Email: clinic@cffhp.com

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