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Please Fill Out Our Patient Intake Form

Birthday
Do you experience pain while eating or chewing?
Yes
No
Do you clench or grind your teeth, especially at night?
Do you experience difficulty in opening or closing your mouth?
Do you have difficulty speaking or swallowing?
Yes
No
Do you experience headaches along with your jaw pain?
Do you have neck pain or stiffness?
Yes
No
Do you experience ear pain or ringing in your ears (tinnitus)?
Yes
No
Do you have any facial muscle tenderness or fatigue?
Yes
No
Do you have a high-stress lifestyle or experience frequent stress?
Yes
No
Other

Thank you for taking the time to complete this questionnaire. Your responses will help us create a personalized treatment plan to address your jaw pain and improve your overall function and well-being

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