Has your sleep partner complained that you grind or gnash your teeth in your sleep? *

Yes

No

Do you experience chronic or severe facial pain concentrated near your jawbone, around your mouth, and/or below your ears? *

Yes

No

Do you suffer from migraines? *

Yes

No

Are you prone to headaches, neck pain, and shoulder pain? *

Yes

No

Does your jawbone area hurt when you eat, drink, or move your mouth? *

Yes

No

Have you ever experienced unexplainable ringing in the ears? *

Yes

No

Do you wake up in the morning and experience facial pain, soreness of the tissues around the jawbone, or headaches? *

Yes

No

Does your jaw make popping or clicking noises when your mouth moves? *

Yes

No

Name *

First Name

Last Name