Have you experienced jaw pain?
Yes, frequently Occasionally Rarely Not at all
How severe is your teeth grinding?
Very severe Moderate Mild None
What solutions have you tried?
Mouth guards Physical therapy Medication None
How effective were the solutions?
Very effective Somewhat effective Not effective Haven't tried
Are you interested in treatment?
Yes, definitely Maybe Not right now No, not interested
How did you hear about us?
Friend/Family Social Media Online Search Other
All set, how can we reach you?
Name
Email
Phone
(Details here)
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