Headache Checklist

Name

Phone Number

E-Mail Address

Preferred Method of Contact

Email Phone

Do you have any of the following?

Heachaches/migraines?

yes no

Soreness or Pain in the Facial Muscles?

yes no

Neck and/or shoulder pain?

yes no

Jaw Pain or Noise?

yes no

Ringing in the Ears (Tinnitus)?

yes no

Tender, Sensitive Teeth?

yes no

Clenching or Grinding of the Teeth?

yes no

Cracking, chipping, or breaking dental restorations?

yes no

Worn or Cracked Teeth?

yes no

Abnormal Wear of the Teeth?

yes no