Athletic Mouthguard Pre-Survey

~ Student Information ~

Your name*

Your date-of-birth*

Your sex at birth:*

Male

Female

Undefined

Your phone number*

Phone

Your email address*

~ School, Sport & Mouthguard Information ~

What school do you attend?*

What sport do you play?*

*Check all that apply

Basketball

Cheer Team

Drill Team

Wrestling

Do you wear a mouthguard during sports?*

Yes

No

When do you wear your current mouthguard?*

Always

Sometimes

Never

My current mouthguard is a:*

Pre-formed stock mouthguard

Boil and bite mouthguard

Custom fabricated mouthguard by the dentist

I don't have a mouthguard

My current mouthguard feels:*

Comfortable

Uncomfortable

Have you experienced an injury to your face when wearing your current mouthguard?*

Yes

No

I don't have a mouthguard

Have you experienced an injury to your face during sports when NOT wearing a mouthguard?*

Yes

No

Do you feel that your current mouthguard is protecting you from injuries or trauma?*

Yes

No

Is it mandatory for you to wear a mouthguard during sports?*

Yes

No

Do you wear braces?*

Yes

No

Why do you want a custom fabricated mouthguard?*

*Check all that apply

It protects better

It’s more comfortable

It looks better

It’s free