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Patient Name: Date: TMD Disability Index Questionnaire

Patient name : _____Date: _____Patient Signature: _____Therapist Signature: _____Date _____TMD Disability Index QuestionnaireDate _____Please check the one statement that best pertains to you (not necessarily exactly) in each of the following 1 - Communication (Talking) I can talk as much as I want without pain, fatigue or discomfort. I talk as much as I want, but it causes some pain, fatigue and/or discomfort. I can't talk as much as I want because of pain, fatigue and/or discomfort. I can't talk much at all because of pain, fatigue and/or discomfort.

Section 10 - Dizziness (Lightheaded, Spinning and/or Balance Disturbance) I do not experience dizziness. I experience dizziness, but it does not interfere with my daily activities. I experience dizziness which interferes somewhat with my daily activities, but I can accomplish my set goals.

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