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Post Trial Dentist Lead Clinical Assessment
On Examination
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* Indicates required question
Email
*
Your email
Name
*
Your answer
Patient Address
Your answer
Date of birth
*
MM
/
DD
/
YYYY
Gender
*
Male
Female
Prefer not to say
Email Address
Your answer
Inter – incisal distance on 1st opening (in mm)
Your answer
Is there pain on opening?
*
Yes
No
Inter – incisal distance on maximal stretch ( in mm)
*
Your answer
Is there pain at stretch?
*
Yes
No
Clicking or crepitus on opening/closing?
*
Opening
Closing
Neither
Both
Deviation from the midline on opening?
*
None
Deviates to the left
Deviates to the right
Overjet (in mm - if reverse overjet please indicate with a negative value)
Your answer
Overbite in mm (if anterior open bite please indicate)
Your answer
Skeletal Class
*
I
II
III
Masseteric hypertrophy present?
*
Yes
No
Masseteric tenderness on palpatation?
Yes RHS
Yes LHS
Both
No
Clear selection
Temporalis hypertrophy present?
*
Yes
No
Temporalis tenderness on palpatation?
Yes RHS
Yes LHS
Both
No
Clear selection
Sternocleidomastoid hypertrophy present?
*
Yes
No
Sternocleidomastoid tenderness on palpatation?
Yes RHS
Yes LHS
Both
No
Clear selection
Lateral pterygoid tenderness (if possible)
*
Yes RHS
Yes LHS
Both
No
Any other comments?
Your answer
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