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Patients Name
Date
Answer all the questions related to your condition.
Is the ringing in your ear(s) on one or both sides?
Select from these options
Right Side
Left Side
Both Ears
Have you had your hearing checked?
Select Yes Or No
Yes
No
Is your tinnitus related to stress?
Select Yes Or No
Yes
No
Is your hearing normal on the side it is ringing?
Select Yes Or No
Yes
No
Is the ringing associated with any trauma?
Select Yes Or No
Yes
No
Do you have pain in the ear where the ringing is occurring?
Select Yes Or No
Yes
No
Do you have pain in the ear on the opposite side the ringing is occurring?
Select Yes Or No
Yes
No
Did your tinnitus begin when your TMD symptoms began?
Select Yes Or No
Yes
No
Is your tinnitus worse when your TMD symptoms are worse?
Select Yes Or No
Yes
No
Does your tinnitus change with jaw movement?
Select Yes Or No
Yes
No
If Yes, Provide A Brief Description
Does your tinnitus change with clenching?
Select Yes Or No
Yes
No
Does your tinnitus fluctuate in intensity?
Select Yes Or No
Yes
No
If Yes, Provide A Brief Description
Is your tinnitus accompanied by fullness/stuffiness in the same ear?
Select Yes Or No
Yes
No
Does your tinnitus have 2 or more sounds?
Select Yes Or No
Yes
No
Did/does your tinnitus come on gradually?
Select Yes Or No
Yes
No
Is your tinnitus related to loud noise?
Select Yes Or No
Yes
No
Do you have a dental splint?
Select Yes Or No
Yes
No
Does your tinnitus change when wearing the dental splint?
Select Yes Or No
Yes
No
If Yes, Provide A Brief Description
Phone
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Home
About
Treatments
Patient Resources
Doctor Forms
Telemedicine
Educational
Myo Smilz
Bimaxillary Case Study
Links
FAQ
Testimonials
Contact
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