Name
Date
Phone
Email
Jaw Pain / Tension
Jaw Pain
Facial Soreness
Locking Jaw
Clicking or Popping Jaw
Tooth Sensitivity
Which side is affected?
Left
Right
Both
Unsure
Migraines / Headaches
Migraines
Morning Headaches
Headaches During the Day
Tension Headaches
Sinusitis / Facial Pressure
Sinus Pressure
Facial Pain / Pressure
Swelling Under Eye
Frequent Sinus Infections
Ringing in the Ears
Ringing in the Ears (Tinnitus)
Ear Fullness or Pressure
Poor Sleep
Restless Sleep
Waking Up Tired
Frequent Waking During the Night
Daytime Fatigue
Stress & Wellness
Anxiety or Stress-Related Tension
Neck Pain
Shoulder Tension
Daytime Clenching
Pain / Discomfort Scale
1
2
3
4
5
6
7
8
9
10
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