Name *

First Name

Last Name

Phone *

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Are you aware of noises in the jaw joints?

Yes

No

Do your jaws feel stiff, tight, or tired after eating?

Yes

No

Do you have any sounds, feelings, or discomfort in your ear(s)?

Yes

No

Do you have bad headaches or migraines?

Yes

No

Have you had Orthodontic treatment?

Yes

No

Do you grind or clench your teeth?

Yes

No

Is stress/anxiety a problem?

Yes

No

Have you ever had whiplash or any head or neck trauma?

Yes

No

Best time to reach you

Daytime

Evening