"*" indicates required fields

Please Answer Yes Or No To The Following:

Bite And Jaw Joint
1. Do you have problems with your jaw joint? (pain, sounds, limited opening, locking, popping)*
2. Do you feel like your lower jaw is being pushed back when you try to bite your back teeth together?*
3. Do you avoid or have difficulty chewing gum, carrots, nuts, bagels, baguettes, protein bars, or other hard, dry foods?*
4. In the past 5 years, have your teeth changed (become shorter, thinner, or worn) or has your bite changed?*
5. Are your teeth becoming more crooked, crowded, or overlapped?*
6. Are your teeth developing spaces or becoming more loose?*
7. Do you have trouble finding your bite, or need to squeeze, tap your teeth together, or shift your jaw to make your teeth fit together?*
8. Do you place your tongue between your teeth or close your teeth against your tongue?*
9. Do you chew ice, bite your nails, use your teeth to hold objects, or have any other oral habits?*
10. Do you clench or grind your teeth together in the daytime or make them sore?*
11. Do you have any problems with sleep (i.e. restlessness or teeth grinding), wake up with a headache or an awareness of your teeth?*
12. Do you wear or have you ever worn a bite appliance?*
Smile Characteristics
13. Is there anything about the appearance of your teeth that you would like to change (shape, color, size)?*
14. Have you ever whitened (bleached) your teeth?*
15. Have you felt uncomfortable or self conscious about the appearance of your teeth?*
16. Have you been disappointed with the appearance of previous dental work?*
This field is for validation purposes and should be left unchanged.