OC OROFACIAL MYOLOGY
PATIENT INTAKE FORM
NAME:
*
First Name
Last Name
AGE:
DATE OF BIRTH:
*
/
Month
/
Day
Year
Date
Street
City
State
Zip
Email
*
example@example.com
PHONE:
*
NAME OF PARENT OR GUARDIAN IF PATIENT IS A MINOR:
REFERRED BY:
MEDICAL HISTORY & RESPIRATION:
Check what pertains to you most of the time.
1. When awake, lips are
together
apart
2. When asleep, lips are
together
apart
3. Is snoring or audible breathing present when asleep?
yes
no
4. Do you have difficulty getting air through your nose?
yes
no
5. Do you have difficulty putting lips together?
yes
no
6. Do you frequently have a sore throat?
yes
no
7. Do you have respiratory allergies?
yes
no
If yes, what medication?
8. Do you have asthma?
yes
no
If yes, what medication?
9. Do you blow your nose often?
yes
no
10. Do you have a history of ear infections?
yes
no
11. Do you have a history of frequent tonsillitis?
yes
no
If yes, how frequent?
12. Have your tonsils been removed?
yes
no
If yes, when?
13. Have your adenoids been removed?
yes
no
If yes, when?
14. Have you been diagnosed with sleep apnea?
yes
no
15. Have you had any other serious injury, surgery, and/or medical diagnosis? If yes, please explain.
Comments:
TEETH:
1. Are you presently wearing braces?
yes
no
a) If yes, for how long and when will you get them off?
Has your orthodontist ever expressed difficulty in getting your teeth to move or stay properly?
yes
no
Briefly describe your teeth before you got your braces:
b) If no, have you worn braces before?
yes
no
If yes, when?
2. Are you presently wearing, or have you worn, any of the following? (When?)
Palatal Expander
Thumb Reminder Device
Retainers
Elastics
Other
Comments:
ORAL HABITS:
1. I currently suck my
thumb
fingers
or use a pacifier
Would you like to stop?
yes
no
2. I used to suck my
thumb
fingers
or use a pacifier
When did you stop?
3. Do you currently bite your fingernails?
yes
no
4. Do you chew/suck on objects, such as
straws
pencils
clothing
toys
jewelry
hair
Other
Comments:
EATING AND DRINKING:
Check what pertains to you most of the time.
1. Do you take
big bites
small bites or
average bites of food
2. Do you eat
quickly
slowly or
at an average pace
3. When chewing, your mouth is
open
closed
4. Do you have difficulty swallowing dry foods without liquid?
yes
no
5. Do you need a drink after each bite to get the food down?
yes
no
6. Do you have difficulty swallowing pills?
yes
no
7. Do you have excessive indigestion after you eat?
yes
no
8. Have you been diagnosed with a tongue-tie or a lip-tie?
yes
no
9. Did you ever have difficulty nursing, taking a bottle, or eating as an infant?
yes
no
Comments:
JAW OR FACIAL PAIN:
Have you ever experienced any of the following? Please check all that apply:
Clicking or popping of the jaw while opeing the mouth
Grating sound in the jaw joint
Pain while opening the jaw
Jaw muscles painful to touch
Jaw locking
Pain or discomfort in jaw while chewing or swallowing
Jaw juts forward, backward, or to the side
Clenching teeth together when not talking or eating
Frequent headaches
Dizziness
Ringing or rushing ear sounds
Hearing change
Restricted jaw opening
Tired jaw muscles
Grinding teeth during sleep
2. What do you think is the cause of your pain or discomfort?
3. What aggravates your pain or discomfort?
4. What makes it feel better?
Comments:
SPEECH:
1. Do you currently or have you previously had difficulty saying any sounds?
yes
no
a) If yes, did you have speech or myofunctional therapy?
yes
no
Was it effective?
yes
no
How long did you have speech and/or myofunctional therapy?
Comments:
CONSENT:
Check the box below
*
I give consent for a certified Speech-Language Pathologist at OC Orofacial Myology, Inc. to conduct a swallowing and/or speech evaluation, through teletherapy, which may include an orofacial exam and other swallow or speech related tests that are deemed necessary to make a clinical diagnosis.
Check the box below:
*
I understand that payment of the assessment fee of $275.00 is due and payable at time of the evaluation.
Check the box below:
*
I give consent for OC Orofacial Myology, Inc. to communicate clinical findings by consultation, phone, email or postal service with the doctor listed below:
Name of Referring Doctor
*
SIGNATURE OF PATIENT OR PARENT/LEGAL GUARDIAN OF MINOR
*
DATE
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: