Have you had any dental work done recently?

Yes

No

Have you had any trauma to your head, neck or face recently?

Yes

No

Are you missing any teeth? (Not including wisdom teeth)

Yes

No

Do you have any partials or dentures?

Yes

No

Are you currently in orthodontics or plan to get braces in the near future? (This Includes invisalign)

Yes

No

Do you have any permanent retainers, crowns, or veneers?

Yes

No

Do you have any major dental work planned?

Yes

No

Do you have TMJ related issues such as jaw pain or limited mouth opening?

Yes

No

Have you ever been diagnosed with sleep apnea?

Yes

No

Have you tried CPAP?

Yes, I slept great with it.

Yes, I tolerated it.

Yes, I couldn't stand it.

No

Have you ever worn a nightguard or other oral appliance?

Yes

No

Do you have any sensitivities (allergic) to metal?

Yes

No

Do you have periodontal disease?

Yes

No

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