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TMD Consult
In order to provide you a virtual consultation and assess your dental concerns, please submit your information below.
Your information will be securely sent back to our team to evaluate.
1. Do you have a grating, clicking or popping sound in either or both jaws when you chew?
2. Is your jaw painful or locked when you wake up in the morning?
3. Do you feel discomfort or muscle pain when chewing?
4. Do you have frequent headaches?
5. Do you feel neck and/or shoulder pain?
6. Do you feel pain in your ear, or near it?
7. Do you perceive any TMJ noise?
8. Do you clench your teeth during the day?
9. Do you grind your teeth at night?
10. Do you have difficulty or pain, or both, when chewing, talking, or using your jaw?
11. Are you aware of noises in the jaw joints?
12. Do you have pain in or about the ears, temples, or cheeks?
13. Does your bite feel uncomfortable or unusual?
14. Have you had a recent injury to your head, neck, or jaw?
15. Have you previously been treated for a jaw joint problem?
Overbite & Overjet
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Upper Arch & Lower Arch
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Right Bite & Left Bite
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First Name
Last Name
Date Of Birth
Phone
Email
Preferred Contact Method
Preferred Contact Time
Notes, Comments, or Questions
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