Bruxism Treatment Orthodontic Evaluation Form
Please complete this form to help us assess your bruxism symptoms and orthodontic needs. All information is confidential.
Patient Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Contact Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
What is your primary reason for seeking evaluation?
*
How often do you experience the following bruxism symptoms?
*
Rows
Never
Rarely
Sometimes
Often
Always
Teeth grinding at night
1
2
3
4
5
Jaw muscle soreness
6
7
8
9
10
Morning headaches
11
12
13
14
15
Tooth sensitivity
16
17
18
19
20
Jaw clicking or popping
21
22
23
24
25
How would you rate the severity of your bruxism symptoms overall?
*
Mild
1
2
3
4
5
6
7
8
9
Severe
10
1 is Mild, 10 is Severe
Do you have any of the following risk factors or triggers for bruxism? (Select all that apply)
Stress or anxiety
Sleep disorders
Caffeine consumption
Alcohol use
Certain medications
Other
Have you previously received any orthodontic or dental treatment for bruxism?
*
Yes
No
Please list any current medications or relevant medical conditions.
Signature (please sign to confirm your consent)
*
Submit Evaluation
Submit Evaluation
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