JawGuard Follow Up Assessment
JawGuard Questionnaire
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Email *
Patient Name *
Patient Address
Patient Email Address
Patient Date of Birth
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Patient Gender
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Are you currently suffer from any of the following conditions? (please tick as appropriate) *
Do you now suffer with generalised pain or aching from your teeth or jaw? *
On a scale of 1 – 10 with 10 being the most pain you have ever felt, what is the worst pain you’ve had from your teeth or jaw since wearing your JawGuard device? *
Have you needed to take pain relief such as ibuprofen or paracetamol for any jaw pain since wearing your JawGuard device? *
Is there anything that has made your jaw associated pain worse since wearing your JawGuard device? *
Please tick below where you have experienced jaw or mouth related pain since wearing your JawGuard device. *
Required
Have you had a clicking noise from your jaw when you speak or eat since wearing your JawGuard device? *
Have you experience a creaking or crunching noise from your jaw when speaking or eating since wearing your JawGuard device? *
Have you experienced tightness or a reduction in how far you can open your mouth since wearing your JawGuard device? *
On a scale of 1 – 10 with 10 being unable to open your mouth at all and 1 being normal and comfortable opening, how would you rate your ability to open your mouth since wearing your JawGuard device? *
Have you found chewing uncomfortable or difficult​ since wearing your JawGuard device? *
On a scale of 1 – 10 with 10 being unable to chew anything, how would you rate your ability to chew since wearing your JawGuard device? *
On a scale of 1 – 10 with 10 being intensely worried, how would you rate how much you have worried about jaw or dental problems since wearing your JawGuard device? *
On a scale of 1 – 10 with 10 being intensely self conscious, how would you rate how self conscious you have been because of your jaw, teeth or mouth​ since wearing your JawGuard device? *
Have you felt miserable because of jaw problems since wearing your JawGuard device? *
Have you needed to alter your eating habits because of problems with your jaw, teeth or mouth since wearing your JawGuard device? *
Have you had an interruption to your sleep because of problems with your jaw, teeth or mouth since wearing your JawGuard device? *
Have you felt depressed because of problems with your jaw, teeth or mouth since wearing your JawGuard device? *
On a scale from 1 – 10 with 10 being unable to do any work, how would you rate how problems with your jaw, teeth or mouth have affected you doing your normal job since wearing your JawGuard device? *
On a scale of 1 – 10 with 10 being 100% affected, how would you rate the effect of jaw or mouth problems has had on your overall quality of life since wearing your jaw guard device ? *
When did you notice improvements in symptoms once you started wearing your jaw guard appliance? *
I feel tense or “wound up”: *
I still enjoy the things I used to enjoy: *
I get a frightened feeling as if something awful is about to happen *
I can laugh and see the funny side of things *
Worrying thoughts go through my mind: *
I feel cheerful
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I can sit at ease and feel relaxed *
I feel as though I am slowed down *
I get a sort of frightened feeling like butterflies in the stomach *
I have lost interest in my appearance *
I feel restless and feel I have to be on the move all the time *
I look forward with enjoyment to things *
I get a sudden feeling of panic *
I can enjoy a good book or radio or TV programme *
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