You can always press Enter⏎ to continue
Welcome
Hi there, please fill out and submit this form.
9
Questions
START
1
Full Name
First Name
Last Name
Previous
Next
Submit
Press
Enter
2
Do you hear any popping or clicking sounds when you open or close your mouth?
YES
NO
Previous
Next
Submit
Press
Enter
3
Have you felt any pain while opening your mouth?
YES
NO
Previous
Next
Submit
Press
Enter
4
Do you find yourself grinding or clenching your teeth during the day or at night?
YES
NO
Previous
Next
Submit
Press
Enter
5
Have you been told that you snore?
YES
NO
Previous
Next
Submit
Press
Enter
6
Do you get headaches or migraines?
YES
NO
Previous
Next
Submit
Press
Enter
7
Do any of these sound familiar?
Ringing sensation in ears
Ears feel blocked
N/A
Previous
Next
Submit
Press
Enter
8
Let us know if you have pain in any of these areas:
Your Jaw
Your Face
Your Neck
Your Shoulder
N/A
Previous
Next
Submit
Press
Enter
9
Email
example@example.com
Previous
Next
Submit
Press
Enter
Should be Empty:
Question Label
1
of
9
See All
Go Back
Submit