Please read this section before you click the link to complete our online questionnaire. 

The new patient form is Not Phone Friendly.  Please work from a 12” diagonal screen or larger; use a keyboard that you like to use; and have a mouse for dragging graphic elements. Dr. Scott needs details before we can schedule the consultation appointment. Having a complete medical history and details of the current problem documented in the questionnaire will make the consultation more productive and interactive.

In thinking about your medical history and your current symptoms, keep in mind that these problems are usually slow to develop and you likely have symptoms that you did not think were related.  For instance, ear pain, muffled hearing, vertigo, balance problems.  These issues may not be related, but many of our patients have ear symptoms.  When the lower jaw is positioned too far back, the bone can make contact with the bone of the exterior ear canal.      

The jaw joints are also just behind the eyes, below the sinuses, and behind a major nerve bundle in the head and neck.  As jaw joint inflammation builds-up slowly, a variety of chronic symptoms may develop. 

The symptom checklist may seem overly broad. Some issues may seem unrelated to the jaw joints. In any case, check any of the listed problems from the past and present.  If you have additional information, add it to any text box in the form and we will put it in the right place.  

The TM joints are the most active joints in the body in terms of movements per day. Twelve sets of muscles move and position the lower jaw. The muscles extend to the top of the head down the neck to the shoulders. Nearly any muscle in the face, head, neck, and shoulders may have pain and tension related to the TMJ. TM-joint issues are strongly associated with muscle pain.

We also have many questions about accidents and head trauma, sometimes we repeat questions.  Accidents are easy to forget over time.  Read each question and take your time. Review your past by decade, by addresses, by schools and jobs. Include childhood accidents, falls, strikes to the jaw or face or bruising or stitches on your upper body.

If you later remember an important detail of your history, let us know so we can update our records.

Page ten of the questionnaire is very helpful for Dr. Scott!  Show us exactly where pain is located, how big an area issues pain, and if it mild, moderate, or severe using colors.   You can show the type of pain.  For instance, use the letter "S" for “sharp," pain and the intensity of pain by your choice of colors from mild to severe.

Page ten takes extra time, at first.  Plan on slowing down here to figure it out. Read the short instructions and practice first.  Drop anything anywhere to see how it works.  We'll show you how clear the form of all your practice.

There are three steps to adding information to the graphic:

1. Select an item by clicking it once and RELEASE the mouse button. The item sticks to the mouse pointer.  It is a different approach, but it does work.  

2. Move the mouse with the item dangling on the tip of the mouse pointer to the person outline over one of the ears or eyes.    

3. Click the once and RELEASE the button.  The item will drop and stick on the human form.  Use “Undo” if you don’t like the position.

Repeat these three steps as many times as you need.  At first this will take some practice, but after a minute, you can drop items quickly. 

Note the color blocks show pain intensity, the location of pain, and the total area of pain. Drop as many color blocks as needed to show the entire area of a particular pain. Remember to DROP LETTERS near areas of pain to indicate the type of pain, for instance, place a letter “P” for pressure.

When you finish practicing, click “clear page” once and then you can start showing Dr. Scott exact details of the pain you may be having.  

If this diagram just does not work for you, draw a diagram similar to the one on the screen and bring it with you to the consultation.

When you get to page 11, go back through each page and make additions and changes.  Go back to any page in the form to make additions or changes.  Again, feel free to enter any text in any text box. We will move it around as needed. When you are satisfied with the entire questionnaire, go to page 11, and keep clicking until you click, "Submit Form."

After you get started, if you decide not to complete the form, just close the tab or the browser. No information will be recorded, kept or saved on your computer or tablet or sent to Dr. Scott. 

Completing your patient history in detail is important.  Dr. Scott reviews the questionnaire twice.  This form provides and orientation to your story before you face to face.  This allows her to ask specific questions.  The time you spend on this form will give you more time in the consultation to ask questions and have a discussion. 

Plan to spend an hour on the questionnaire.  Pick a time when you will not be interrupted. After Dr. Scott has reviewed your, we will contact you to schedule.  

Copy and Paste the Link Below:


TEXT: 615 476 4193 

EMAIL: Admin@TMJRehabilitation.com. 


Steve Roberts

Administrator for Dr.Cheryl Ann Scott