Bruxism Screening Questionnaire

Full Name

Age

1. Do you grind or clench your teeth during the day or night?

Yes No

2. Has anyone told you that you grind your teeth while sleeping?

Yes No

3. Do you frequently wake up with jaw pain or stiffness?

Yes No

4. Have you experienced headaches after waking up?

Yes No

5. Do you have damaged or worn-down teeth?

Yes No

6. Do you experience tension or soreness in your jaw muscles?

Yes No

7. Do you have difficulty opening or closing your mouth?

Yes No

Additional Notes