Does your child grind his/her teeth?	No/ yes/ unknown
Does your child have pain in the face, jaw, temple, in front of the ear or in the ear?	No/ yes
Does the jaw make a clicking or popping sound when your child opens or closes the mouth, or while chewing?	No/ occasionally/ regularly/ often/ very often
Does your child experience pressure and/or tension from the home situation?	No/ occasionally/ regularly/ often/ very often
Do you think your child is in a state of mental tension when he/she gets home from school?	No/ occasionally/ regularly/ often/ very often
Does your child worry about things?	No/ occasionally/ regularly/ often/ very often
Is your child easily scared?	No/ occasionally/ regularly/ often/ very often
Does your child experience difficulties in falling asleep?	No/ occasionally/ regularly/ often/ very often