Tinnitus And Tmd Patietnt Form Patients NameDateAnswer all the questions related to your condition. Is the ringing in your ear(s) on one or both sides?Select from these optionsRight SideLeft SideBoth EarsHave you had your hearing checked?Select Yes Or NoYesNoIs your tinnitus related to stress? Select Yes Or NoYesNoIs your hearing normal on the side it is ringing?Select Yes Or NoYesNoIs the ringing associated with any trauma?Select Yes Or NoYesNoDo you have pain in the ear where the ringing is occurring? Select Yes Or NoYesNo Do you have pain in the ear on the opposite side the ringing is occurring? Select Yes Or NoYesNoDid your tinnitus begin when your TMD symptoms began? Select Yes Or NoYesNoIs your tinnitus worse when your TMD symptoms are worse? Select Yes Or NoYesNoDoes your tinnitus change with jaw movement? Select Yes Or NoYesNoIf Yes, Provide A Brief DescriptionDoes your tinnitus change with clenching? Select Yes Or NoYesNoDoes your tinnitus fluctuate in intensity?Select Yes Or NoYesNoIf Yes, Provide A Brief DescriptionIs your tinnitus accompanied by fullness/stuffiness in the same ear? Select Yes Or NoYesNoDoes your tinnitus have 2 or more sounds? Select Yes Or NoYesNoDid/does your tinnitus come on gradually?Select Yes Or NoYesNoIs your tinnitus related to loud noise? Select Yes Or NoYesNoDo you have a dental splint?Select Yes Or NoYesNoDoes your tinnitus change when wearing the dental splint? Select Yes Or NoYesNoIf Yes, Provide A Brief DescriptionCommentSubmit
