Am I a candidate for the Spot Pal?
Who is this assessment form for?
*
Myself
Child
Age of potential user:
*
Has the Spot Pal candidate been diagnosed with a tongue-thrust?
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Yes
No
Does the Spot Pal candidate present with any sleep concerns, including but not limited to snoring, restless sleeping, mouth breathing in sleep, poor sleep quality?
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Yes
No
Does the spot pal candidate clench or grind their teeth?
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Yes
No
Has the Spot Pal candidate been diagnosed with a tongue thrust, which is impacting his palate or teeth?
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Yes
No
Have you or your child had braces, yet feel the teeth have shifted?
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Yes
No
Do you or your child currently present with any type of oral fixation such as mouthing objects, tongue sucking, nail biting, thumb/finger sucking, excessive lip licking/lip biting?
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Yes
No
Has the Spot Pal candidate been diagnosed with a tongue thrust impacting his speech?
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Yes
No
Does the Spot Pal candidate present with any difficulties producing any of the following sounds: s, z, r, sh, ch, j, t, d, l, n?
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Yes
No
What would you like the Spot Pal to help with?
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score2
Name
*
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
How did you hear about Spot Pal?
*
*Your results will be displayed once the form is submitted
Submit
Should be Empty: