Jaw Functional Limitation Scale

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

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* 2. Who is your Physiotherapist?

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* 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 hard bread
Chew chicken (for example, prepared in oven)
Chew crackers
Chew soft food (for example, macaroni, canned or soft fruits, cooked vegetables, fish)
Eat soft food requiring no chewing (for example, mashed potatoes, apple sauce,
pudding, pureed food)
Open wide enough to bite from a whole
apple
Open wide enough to bite into a sandwich
Open wide enough to talk
Open wide enough to drink from a cup
Swallow
Yawn
Talk
Sing
Putting on a happy face
Putting on an angry face
Frown
Kiss
Smile
Laugh

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* 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.

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