| 1. Do you have difficulty opening your mouth wide? |
| 2. Do you have difficulty moving your jaw to the sides? |
| 3. Do you feel fatigue or muscle pain when you chew? |
| 4. Do you have frequent headaches? |
| 5. Do you have neck pain or a stiff neck? |
| 6. Do you have ear aches or pain in that area (TMJ)? |
| 7. Have you ever noticed any noise in your TMJ while chewing or opening your mouth? |
| 8. Do you have any habits such as clenching or grinding your teeth? |
| 9. Do you feel that your teeth do not come together well? |
| 10. Do you consider yourself a tense (nervous) person? |