Client Intake - JFLS Survey

Welcome to Resolution Physiotherapy & IMS Clinic and thank you for choosing our team of Physiotherapists to help resolve your pain. We look forward to meeting you and showing you how effective our team of highly qualified Physiotherapists can be.

Please complete this questionnaire if our Physiotherapists are treating you for TMJ (jaw) pain.

	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

No limitation 0

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

Client Intake - JFLS

TMJ (Jaw) Questionnaire

Question Title

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

Question Title

Question Title

* 3. 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)

Question Title

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

Question Title

Question Title

* 3. 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)

* 3. 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)