Post Trial Dentist Lead Clinical Assessment
On Examination
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Email *
Name *
Patient Address
Date of birth *
MM
/
DD
/
YYYY
Gender *
Email Address
Inter – incisal distance on 1st opening (in mm)
Is there pain on opening? *
Inter – incisal distance on maximal stretch ( in mm) *
Is there pain at stretch? *
Clicking or crepitus on opening/closing? *
Deviation from the midline on opening? *
Overjet (in mm - if reverse overjet please indicate with a negative value)
Overbite in mm (if anterior open bite please indicate)
Skeletal Class *
Masseteric hypertrophy present? *
Masseteric tenderness on palpatation?
Clear selection
Temporalis hypertrophy present? *
Temporalis tenderness on palpatation?
Clear selection
Sternocleidomastoid hypertrophy present? *
Sternocleidomastoid tenderness on palpatation?
Clear selection
Lateral pterygoid tenderness (if possible) *
Any other comments?
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