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JVA Referrals

Joint Vibration Analysis (JVA) referrals

Thank you for your referral. If you fill out this form, we will contact your patient to arrange an appointment as soon as possible.

Please fill out the form online and press submit when you have finished. Alternatively, for a printed form, click on this link and print out the PDF version of the form, then fill it in. You can either give it to your patient to bring when they come for their appointment, or send it in advance to our postal address: Granta Dental,  Newnham Road, Cambridge, CB3 9EY.

  • Please will you arrange a JVA screening for:

    0
  • Forename*
    1
  • Surname*
    2
  • Date of birth*
    3
  • Address*
    4
  • Postcode*
    5
  • Daytime phone number*
    6
  • Evening telephone number*
    7
  • Mobile telephone number*
    8
  • Email*
    9
  • Please select one of the following actions you wish us to take*
    Basic JVA screening only
    JVA screening and analysis report
    JVA and muscle function analysis and report
    10
  • Practitioner contact information

    11
  • Referring practitioner's name*
    12
  • Practitioner's practice address*
    13
  • Practitioner's practice telephone number*
    14
  • Practitioner's mobile number*
    15
  • Practitioner's email address*
    16
  • Clinical assessment

    17
  • 1. Chief complaint/symptom*
    18
  • Duration of chief complaint/symptom*
    Days
    Weeks
    Months
    Years
    19
  • 2. History of trauma to face, head or neck*
    20
  • When?*
    21
  • 3. Past history of pain in TMJ*
    22
  • When?*
    23
  • Previous TMJ treatment

    24
  • Surgical*
    25
  • Non-surgical*
    Splints
    Mouthguards
    Bite raising
    Appliances
    Occlusal adjustment
    26
  • Is joint noise present?*
    Right
    Left
    Both
    None
    27
  • Tenderness in masseter or temporalis muscles?*
    Right
    Left
    Both
    None
    28
  • Is there any facial asymmetry*
    Yes
    No
    29
  • Is the chin displaced?*
    Right
    Left
    No
    30
  • Range of mandibular movement

    31
  • Maximum opening (millimetres)*
    32
  • Deviation on opening*
    Right
    Left
    Both
    None
    33
  • Maximum protrusion (millimetres)*
    34
  • Lateral excursions

    35
  • Right (millimetres)*
    36
  • Left (millimetres)*
    37
  • Is there an anterior open bite?*
    Yes
    No
    38
  • Has this recently increased?*
    Yes
    No
    39
  • 40