JFLS + PSFS Survey

Question Title

* 1. Please type your name. Surname, First Name

Question Title

* 2. Who is your Physiotherapist?

Mandi Hayes

Jennifer Duke

Anthony Giorgianni

Jeanine Stott

Beata Sadowska

Heather Clegg

Chris Cosby

I cannot remember

Question Title

* 3. For each of the items below, please score your level of limitation from 0 (no limitation) to 10 (severe limitation), during the last month.

If the activity has been completely avoided because it is too difficult, then circle ‘10'.

If you avoid an activity for reasons other than pain or difficulty, then leave it blank and explain why below.

	No limitation 0	1	2	3	4	5	6	7	8	9	Severe Limitation 10
Chew tough food	Chew tough food No limitation 0	Chew tough food 1	Chew tough food 2	Chew tough food 3	Chew tough food 4	Chew tough food 5	Chew tough food 6	Chew tough food 7	Chew tough food 8	Chew tough food 9	Chew tough food Severe Limitation 10
Chew hard bread	Chew hard bread No limitation 0	Chew hard bread 1	Chew hard bread 2	Chew hard bread 3	Chew hard bread 4	Chew hard bread 5	Chew hard bread 6	Chew hard bread 7	Chew hard bread 8	Chew hard bread 9	Chew hard bread Severe Limitation 10
Chew chicken (for example, prepared in oven)	Chew chicken (for example, prepared in oven) No limitation 0	Chew chicken (for example, prepared in oven) 1	Chew chicken (for example, prepared in oven) 2	Chew chicken (for example, prepared in oven) 3	Chew chicken (for example, prepared in oven) 4	Chew chicken (for example, prepared in oven) 5	Chew chicken (for example, prepared in oven) 6	Chew chicken (for example, prepared in oven) 7	Chew chicken (for example, prepared in oven) 8	Chew chicken (for example, prepared in oven) 9	Chew chicken (for example, prepared in oven) Severe Limitation 10
Chew crackers	Chew crackers No limitation 0	Chew crackers 1	Chew crackers 2	Chew crackers 3	Chew crackers 4	Chew crackers 5	Chew crackers 6	Chew crackers 7	Chew crackers 8	Chew crackers 9	Chew crackers Severe Limitation 10
Chew soft food (for example, macaroni, canned or soft fruits, cooked vegetables, fish)	Chew soft food (for example, macaroni, canned or soft fruits, cooked vegetables, fish) No limitation 0	Chew soft food (for example, macaroni, canned or soft fruits, cooked vegetables, fish) 1	Chew soft food (for example, macaroni, canned or soft fruits, cooked vegetables, fish) 2	Chew soft food (for example, macaroni, canned or soft fruits, cooked vegetables, fish) 3	Chew soft food (for example, macaroni, canned or soft fruits, cooked vegetables, fish) 4	Chew soft food (for example, macaroni, canned or soft fruits, cooked vegetables, fish) 5	Chew soft food (for example, macaroni, canned or soft fruits, cooked vegetables, fish) 6	Chew soft food (for example, macaroni, canned or soft fruits, cooked vegetables, fish) 7	Chew soft food (for example, macaroni, canned or soft fruits, cooked vegetables, fish) 8	Chew soft food (for example, macaroni, canned or soft fruits, cooked vegetables, fish) 9	Chew soft food (for example, macaroni, canned or soft fruits, cooked vegetables, fish) Severe Limitation 10
Eat soft food requiring no chewing (for example, mashed potatoes, apple sauce, pudding, pureed food)	Eat soft food requiring no chewing (for example, mashed potatoes, apple sauce, pudding, pureed food) No limitation 0	Eat soft food requiring no chewing (for example, mashed potatoes, apple sauce, pudding, pureed food) 1	Eat soft food requiring no chewing (for example, mashed potatoes, apple sauce, pudding, pureed food) 2	Eat soft food requiring no chewing (for example, mashed potatoes, apple sauce, pudding, pureed food) 3	Eat soft food requiring no chewing (for example, mashed potatoes, apple sauce, pudding, pureed food) 4	Eat soft food requiring no chewing (for example, mashed potatoes, apple sauce, pudding, pureed food) 5	Eat soft food requiring no chewing (for example, mashed potatoes, apple sauce, pudding, pureed food) 6	Eat soft food requiring no chewing (for example, mashed potatoes, apple sauce, pudding, pureed food) 7	Eat soft food requiring no chewing (for example, mashed potatoes, apple sauce, pudding, pureed food) 8	Eat soft food requiring no chewing (for example, mashed potatoes, apple sauce, pudding, pureed food) 9	Eat soft food requiring no chewing (for example, mashed potatoes, apple sauce, pudding, pureed food) Severe Limitation 10
Open wide enough to bite from a whole apple	Open wide enough to bite from a whole apple No limitation 0	Open wide enough to bite from a whole apple 1	Open wide enough to bite from a whole apple 2	Open wide enough to bite from a whole apple 3	Open wide enough to bite from a whole apple 4	Open wide enough to bite from a whole apple 5	Open wide enough to bite from a whole apple 6	Open wide enough to bite from a whole apple 7	Open wide enough to bite from a whole apple 8	Open wide enough to bite from a whole apple 9	Open wide enough to bite from a whole apple Severe Limitation 10
Open wide enough to bite into a sandwich	Open wide enough to bite into a sandwich No limitation 0	Open wide enough to bite into a sandwich 1	Open wide enough to bite into a sandwich 2	Open wide enough to bite into a sandwich 3	Open wide enough to bite into a sandwich 4	Open wide enough to bite into a sandwich 5	Open wide enough to bite into a sandwich 6	Open wide enough to bite into a sandwich 7	Open wide enough to bite into a sandwich 8	Open wide enough to bite into a sandwich 9	Open wide enough to bite into a sandwich Severe Limitation 10
Open wide enough to talk	Open wide enough to talk No limitation 0	Open wide enough to talk 1	Open wide enough to talk 2	Open wide enough to talk 3	Open wide enough to talk 4	Open wide enough to talk 5	Open wide enough to talk 6	Open wide enough to talk 7	Open wide enough to talk 8	Open wide enough to talk 9	Open wide enough to talk Severe Limitation 10
Open wide enough to drink from a cup	Open wide enough to drink from a cup No limitation 0	Open wide enough to drink from a cup 1	Open wide enough to drink from a cup 2	Open wide enough to drink from a cup 3	Open wide enough to drink from a cup 4	Open wide enough to drink from a cup 5	Open wide enough to drink from a cup 6	Open wide enough to drink from a cup 7	Open wide enough to drink from a cup 8	Open wide enough to drink from a cup 9	Open wide enough to drink from a cup Severe Limitation 10
Swallow	Swallow No limitation 0	Swallow 1	Swallow 2	Swallow 3	Swallow 4	Swallow 5	Swallow 6	Swallow 7	Swallow 8	Swallow 9	Swallow Severe Limitation 10
Yawn	Yawn No limitation 0	Yawn 1	Yawn 2	Yawn 3	Yawn 4	Yawn 5	Yawn 6	Yawn 7	Yawn 8	Yawn 9	Yawn Severe Limitation 10
Talk	Talk No limitation 0	Talk 1	Talk 2	Talk 3	Talk 4	Talk 5	Talk 6	Talk 7	Talk 8	Talk 9	Talk Severe Limitation 10
Sing	Sing No limitation 0	Sing 1	Sing 2	Sing 3	Sing 4	Sing 5	Sing 6	Sing 7	Sing 8	Sing 9	Sing Severe Limitation 10
Putting on a happy face	Putting on a happy face No limitation 0	Putting on a happy face 1	Putting on a happy face 2	Putting on a happy face 3	Putting on a happy face 4	Putting on a happy face 5	Putting on a happy face 6	Putting on a happy face 7	Putting on a happy face 8	Putting on a happy face 9	Putting on a happy face Severe Limitation 10
Putting on an angry face	Putting on an angry face No limitation 0	Putting on an angry face 1	Putting on an angry face 2	Putting on an angry face 3	Putting on an angry face 4	Putting on an angry face 5	Putting on an angry face 6	Putting on an angry face 7	Putting on an angry face 8	Putting on an angry face 9	Putting on an angry face Severe Limitation 10
Frown	Frown No limitation 0	Frown 1	Frown 2	Frown 3	Frown 4	Frown 5	Frown 6	Frown 7	Frown 8	Frown 9	Frown Severe Limitation 10
Kiss	Kiss No limitation 0	Kiss 1	Kiss 2	Kiss 3	Kiss 4	Kiss 5	Kiss 6	Kiss 7	Kiss 8	Kiss 9	Kiss Severe Limitation 10
Smile	Smile No limitation 0	Smile 1	Smile 2	Smile 3	Smile 4	Smile 5	Smile 6	Smile 7	Smile 8	Smile 9	Smile Severe Limitation 10
Laugh	Laugh No limitation 0	Laugh 1	Laugh 2	Laugh 3	Laugh 4	Laugh 5	Laugh 6	Laugh 7	Laugh 8	Laugh 9	Laugh Severe Limitation 10

Please explain why any row was left blank here:

Question Title

* 4. Interpretation of scores (for office use only)

Total score: add up the total scores = _______ MDC - not published SCORE RANGE = 0 (max disability) to 200 (no disability)

This questionnaire is taken from: Ohrbach R, Larsson P, List T (2008). The Jaw Functional Limitation Scale: Development, reliability, and validity of 8-item and 20-item versions. Journal of Orofacial Pain 22: 219-230.

Question Title

* 1. Please type your name. Surname, First Name

Question Title

* 2. Who is your Physiotherapist?

Question Title

Question Title

* 4. Interpretation of scores (for office use only)Total score: add up the total scores = _______ MDC - not published SCORE RANGE = 0 (max disability) to 200 (no disability)

* 4. Interpretation of scores (for office use only)

Total score: add up the total scores = _______ MDC - not published SCORE RANGE = 0 (max disability) to 200 (no disability)