Basic information:

How do you assess the general state of your health, I for the last six months, a month?:


Do you often notice irritability and nervousness?:

Am I in a state of chronic stress for a long time?:

Do you have numbness in your fingers?:

Do you have a sleep disorder?:

Do you feel dizzy?:

Do you have pain in the cervical spine?:

Which of these symptoms do you notice in yourself?:

Do you notice pain in the face? Different types of migrating pain?:

Do you have a numb area on your face?:

Hearing impairment? Tinnitus?:

Does it hurt to chew?:

Does it hurt to open your mouth? (You cannot open your mouth as wide as you would like):

Does it hurt to swallow?:

Have you noticed that your teeth have started to wear out and decreased in height?:

Did you notice that your central teeth were bent, rubbed?:

Do you have one or more lateral masticatory teeth?:

If so, how long ago?:

Can't chew food as easily as before?:

Have you noticed any changes or asymmetry in your jaws?:

Have your teeth become sensitive to hot / cold?:

Did your teeth start moving?:

Are you clenching or gnashing your teeth?:

Have you had any head or neck injuries? (accident, blow):

Have you ever undergone dental alignment treatment?:

Have you noticed bleeding gums?:

Do you have various migrating headaches?: