1. Has your sleep partner complained that you grind or clench your teeth in your sleep?*

A. Yes

B. No

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

A. Yes

B. No

3. Do you suffer from migraines?*

A. Yes

B. No

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

A. Yes

B. No

5. Have you experienced numbness in your arms and fingers?

A. Yes

B. No

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

A. Yes

B. No

7. Have you ever experienced unexplainable ringing in the ears?*

A. Yes

B. No

8. Do you experience unexplainable dizziness/vertigo?

A. Yes

B. No

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

A. Yes

B. No

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

A. Yes

B. No

11. Do you have limited mouth opening or has your jaw ever lock up?

A. Yes

B. No

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