Clenching and Grinding Questionnaire
Patient name
Dentist name
Date
/
Month
/
Day
Year
Date
Do you clench or grind your teeth during the day?
*
Yes
No
Have you been made aware of clenching or grinding your teeth during the night?
*
Yes
No
Do you often wake up during the night?
*
Yes
No
Are your jaws or teeth tired when you wake in the morning?
*
Yes
No
Do you feel refreshed when you wake in the morning?
*
Yes
No
Do you suffer from chronic headaches, or neck and shoulder pain?
*
Yes
No
Do you now, or have you ever had pain in your jaw joint or the sides of your face particularly around the ear?
*
Yes
No
Have your jaws ever clicked or locked opened or closed?
*
Yes
No
Do you tend to chew on only one side of your mouth?
*
Yes
No
Have you ever had any dental work (crowns, bridges, fillings, etc) that stopped your teeth biting normally together or felt "in the way"?
*
Yes
No
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