| 1. Do you have morning headaches? |
Yes No |
| 2. Do you have stiff jaws or locked jaws in the morning? |
Yes No |
| 3. Do you have frequent earaches? |
Yes No |
| 4. Do you have more than 2 headaches per week? |
Yes No |
| 5. Do you have jaw pain when you eat? |
Yes No |
| 6. Do you take more than 4 painkillers per week for HA? |
Yes No |
| 7. Does your jaw make noise when you open? |
Yes No |
| 8. Have you noticed a change in your bite? |
Yes No |
| 9. Does your jaw lock on occasion? |
Yes No |
| 10. Is your jaw locked now (can't open wide)? |
Yes No |
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