Questionnaire


Name
 		 *
Surname
 		 *
Phone
 		 *
Email
 		 *

Which age group do you belong to?

 10 - 20
 21 - 30
 31 - 40
 41 - 50
 51 - 60
 61 and above


Do you suffer from any of these symptoms or problems?

... toothaches

 yes
 no


... aching jaws

 yes
 no


... headaches

 yes
 no


... aching neck

 yes
 no


... earaches

 yes
 no


... backaches

 yes
 no


... shoulder pains

 yes
 no


... aching muscles

 yes
 no


... pains when opening your mouth

 yes
 no


... pains when biting or chewing?

 yes
 no


Are you aware of clenching or grinding your teeth?

 yes
 no


Do your gums degenerate?

 yes
 no


Do you suffer from periodontosis?

 yes
 no


Do you suffer from gum bleeding?

 yes
 no


Do your teeth meet when you bite?

 yes
 no


Do you often experience numbness in your lip and/or nose?

 yes
 no


Do you experience difficulties chewing?

 yes
 no


Do you only chew on one side?

 yes
 no


Has one or more of your teeth moved?

 yes
 no


Has one or more of your teeth loosened?

 yes
 no


Are your teeth worn?

 yes
 no


Do you experience much temperature sensitivity in some of your teeth?

 yes
 no


Is there a tooth bothering you when closing your mouth?

 yes
 no


Have you noticed a clicking in your jaw joint?

 yes
 no


Does your mouth often feel dry?

 yes
 no


Are you limited in your ability to open your mouth?

 yes
 no


Did you ever have a difficult wisdom tooth removal?

 yes
 no


Do you already have dental prosthetics?

 yes
 no


Do you tend to wake up with sore, stiff muscles?

 yes
 no


Do you feel a burning sensation in your tongue, or a numb tongue?

 yes
 no


Do you sometimes experience numbness in your arms or fingers?

 yes
 no


Do you suffer from ringing in your ears (tinnitus)?

 yes
 no


Do you have dizziness problems?

 yes
 no


Do you suffer from flickering eyes?

 yes
 no


Do you suffer from impaired vision?

 yes
 no


Do you experience difficulties swallowing?

 yes
 no


Do you experience problems speaking?

 yes
 no


Do you sometimes get "a frog in the throat"?

 yes
 no


Do you have specific hobbies such as playing wind instruments, violin etc.?

 yes
 no


Do you snore?

 yes
 no


Are you missing any front teeth?

 yes
 no


Are you missing any side teeth?

 yes
 no


Do you have a shortened row of teeth (missing back teeth)?

 yes
 no


Are you missing all of your teeth in your upper jaw?

 yes
 no


Are you missing all of your teeth in your lower jaw?

 yes
 no


Do you wear a denture? If so, does it slip or fit badly?

 yes
 no


Are there any plans for you to have a tooth removed soon?

 yes
 no


Are you unhappy with the color of your teeth?

 yes
 no


Do you suffer from caries?

 yes
 no


Have you got problems with bad breath or a bad taste in your mouth?

 yes
 no


Do you wear dentures where metal is visible at the edge of the crown?

 yes
 no


Do you smoke?

 yes
 no


Additional comments:



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