Sleep, Breathing & TMJ Survey

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The symptoms listed below can be related to TMJ pain as well as Sleep Disordered Breathing, including Sleep Apnea. These symptoms are all connected and may indicate a possible airway constriction which can lead to other serious health complications now or in the future, including high blood pressure, stroke and diabetes, as well as loss of productivity, increased risk of a car accident and diminished quality of life!
Airway constriction can also lead to academic struggles, ADD/ADHD symptoms, aggression, anxiety and depression.

Check all that apply to you, or the person you are completing this form for.
AFTER YOU HAVE SUBMITTED THE FORM, click the "View Accuracy" button for interesting information about many of your specific symptoms.

Please complete ONE questionnaire per person (Adult or Child) that you would like a complimentary evaluation of their symptoms for.

Email *

Patient's Name (First & Last) *

Person's Name completing this form (if not the patient)

Patient's Age *

Best Phone Number to reach you for our complimentary evaluation: *

Anger/Aggression

Yes

Excessive Stress

Yes

Anxiety

Yes

Depression

Yes

Mood Swings

Yes

Brain Fog/Difficulty Concentrating

Yes

Daytime Fatigue/Drowsiness

Yes

Academic Struggles

Yes

Deviated Septum

Yes

Difficulty breathing through nose

Yes

Asthma

Yes

Been observed stop breathing while sleeping

Yes

Diabetes

Yes

Over Weight

Yes

High Blood Pressure

Yes

Heart Disease

Yes

Jaw Joint Pain

Yes

Crooked Teeth

Yes

Teeth Grinding/Clenching

Yes

Swollen (or Removed) Tonsils or Adenoids

Yes

Mouth Breathing Day or Night

Yes

Tongue-Tied

Yes

ADD/ADHD

Yes

Snore Loudly

Yes

Migraines/Headaches

Yes

Diagnosed with Sleep Apnea

Yes

Bedwetting

Yes

Neck, Shoulder or Back Pain

Yes

Chronic Fatigue

Yes

I wear partial or full denture(s)

Yes

Please offer any other pertinent information you feel would be helpful for us to know.

A copy of your responses will be emailed to the address you provided.

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