Major Reason for Current Evaluation
3. Describe, in order (first to last), what you expect from your treatment:
Current Stress Factors:
(please check all that apply to you)
1. Do you clench your teeth together under stress?
2. Do you grind/clench your teeth at night?
3. Do you sleep with an unusual head position?
4. Are you aware of any habits or activities that may aggravate this condition?
Please check each that apply to you.
A. HEAD PAIN, HEADACHES, FACIAL PAIN
B. EYE PAIN OR EAR ORBITAL PROBLEMS
C. MOUTH, FACE, CHEEK AND CHIN PROBLEMS
D. TEETH AND GUM PROBLEMS
E. JAW AND JAW JOINT (TMD) PROBLEMS
F. PAIN, EAR PROBLEMS, POSTURAL IMBALANCES
G. OTHER (please explain)
I. NECK AND SHOULDER PAIN
In your own words, tell us where your pain is and how intense it is: