Do you ever experience symptoms of teeth grinding or clenching?
Yes
No
Do you find that you can be grinding your teeth during the day and/or night?
Yes
No
Do you wake up with headaches or aches in your Jaw muscle?
Yes
No
Have you noticed any signs of teeth grinding such as worn tooth enamel, chipped teeth or flattened teeth?
Yes
No
Do you have jaw pain especially when waking up in the morning?
Yes
No
Do you find that your jaw can click?
Yes
No
Have you noticed over the last few years that your jawline has got wider?
Yes
No
Does your partner hear you grind at night
Yes
No
Not Applicable
Have you been offered a mouth guard or splint by your dentist?
Yes
No
Are you in pain and looking for relief?
Yes
No
First Name
Last Name
Phone
*
Email
*