Tmj Symptom Intensity Scale (Sis) Form
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1TMJ SYMPTOM INTENSITY SCALE (SIS)
Name: __________________________ Date: _____________ Date of birth /age: ________/___
Please indicate the intensity of your symptoms as follows:
• Circle the number on the scale to indicate your most usual symptom level
• Draw an X through the number to indicate your most severe symptom level.
1. Jaw Pain
No Pain
0 1 2 3 4 5 6 7 8 9 10
Most intense pain
2. Painful jaw clicking
No Pain
0 1 2 3 4 5 6 7 8 9 10
Most intense pain
3. Jaw locking
No pain to
0 1 2 3 4 5 6 7 8 9 10
Can barely open
open mouth
mouth
4. Headaches
No Pain
0 1 2 3 4 5 6 7 8 9 10
Most intense pain
5. Neck and/or upper
shoulder muscle pain
No Pain
0 1 2 3 4 5 6 7 8 9 10
Most intense pain
6. Dizziness
No
Most intense
0 1 2 3 4 5 6 7 8 9 10
dizziness
dizziness
7. Ringing in the ears
No ringing
0 1 2 3 4 5 6 7 8 9 10
Most intense
ringing
TMJ SYMPTOM FREQUENCY SCALE (SFS)
Please indicate the frequency of your symptoms as follows:
•
Circle the number on the scale to indicate how often you experience the following symptoms
1. Jaw Pain
Never
0 1 2 3 4 5 6 7 8 9 10
100% of the time
2. Painful jaw clicking
Never
0 1 2 3 4 5 6 7 8 9 10
100% of the time
3. Jaw locking
Never
0 1 2 3 4 5 6 7 8 9 10
100% of the time
4. Headaches
Never
0 1 2 3 4 5 6 7 8 9 10
100% of the time
5. Neck pain and/or upper
shoulder muscle pain
Never
0 1 2 3 4 5 6 7 8 9 10
100% of the time
6. Dizziness
Never
0 1 2 3 4 5 6 7 8 9 10
100% of the time
7. Ringing in the ears
Never
0 1 2 3 4 5 6 7 8 9 10
100% of the time
__________________________________________________________________________________________________
↓ ↓ ↓ ↓ FOR OFFICE USE ONLY ↓ ↓ ↓ ↓
Scoring Summary Chart
st
Re-√ √ √ √ __________
nd
Re-√ √ √ √ ___________ 3
rd
Re-√ √ √ √ __________
Initial - Date_____
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2
TMJ Disability Index
TMJ SIS (usual/max.)
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/
/
/
TMJ SFS
Comments:
________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
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Patient's signature _________________________________________ Date________________
Modified: Steigerwald DP, Maher JH. The Steigerwald/Maher TMD Disability Questionnaire. Today's Chiro 1997;26:86-91.
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Parent category: Life