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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.

*Required Information

First and Last Name

Phone

Referring Doctor

Were you referred to a specific Practitioner?

What is your Primary Complaint?

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

Thank you for submitting this form!

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. - 3 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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