Teeth Grinding Evaluation Form
Please complete this form to help assess symptoms and habits related to teeth grinding (bruxism).
How often do you notice yourself grinding or clenching your teeth?
*
Never
Rarely (a few times a month)
Sometimes (a few times a week)
Often (daily)
Unsure
When do you most often grind or clench your teeth?
During sleep
During the day
When stressed or anxious
While concentrating
Other
Please rate the severity of your teeth grinding or clenching.
*
1
2
3
4
5
Which symptoms do you experience regularly?
*
Jaw pain or tightness
Headaches (especially in the morning)
Tooth sensitivity
Earaches
Worn, chipped, or flattened teeth
None of the above
Do you experience jaw clicking or popping?
Yes
No
Occasionally
Have you noticed any changes in your bite or alignment of your teeth?
Yes
No
Not sure
Do you use any of the following for teeth grinding?
Mouthguard/nightguard
Medication
Stress management techniques
None
Other
Please indicate how much the following factors contribute to your teeth grinding.
Rows
Not at all
A little
Moderately
A lot
Stress or anxiety
1
2
3
4
Caffeine intake
5
6
7
8
Sleep disturbances
9
10
11
12
Alcohol consumption
13
14
15
16
Have you consulted a dental or medical professional about your teeth grinding?
Yes, dentist
Yes, physician
No
If you have any additional comments or details regarding your symptoms or habits, please provide them below.
Submit Evaluation
Should be Empty: