TMJ Questionnaire

Are you suffering with TMJ pain? Please fill out the form below and we will follow up with you to address your issues with some helpful insights.

Please provide us with the following information so we can follow-up with you within 48-hours.

First Name *

Last Name *

Email Address *

Phone Number *

What is the best way for us to contact you? *

Phone

Are you experiencing any of the following symptoms? Please check all that apply.

Headaches

Migraines

Jaw pain

Neck and/or shoulder pain

Clicking or popping of the jaw

Limited ability to open your mouth

Ear congestion

Dizziness (Vertigo)

Ringing in the ears (Tinnitus)

Difficulty swallowing (Dysphagia)

Loose teeth

Clenching or grinding of the teeth

Facial and/or sinus pain

Tender, sensitive teeth

Difficulty chewing

Posture problems

Tingling in your fingertips (Paresthesia)

Sensitivity to hot and/or cold

Bells Palsy

Chronic pain disorder affecting your trigeminal nerve (Trigeminal Neuralgia)

Nervousness/anxiety

Insomnia

Other

Please provide any additional information you think might be helpful.

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