OROFACIAL MYOLOGY HISTORY
Therapy Associates, Inc. 13750 Crosstown Dr. NW Ste 106 Phone: 763-444-8700 Fax: 763-434-0192
Patient Name
First Name
Last Name
Date of Birth
Describe your concern(s):
Who referred you to Therapy Associates, Inc?
Dental and Medical Information:
Date of last dental exam
Name of Dentist
Date of last orthodontic treatment
Name of Orthodontist
Are you under the care of a physician?
Yes
No
If yes, what condition is being treated?
Have you been hospitalized over the last 5 years?
Yes
No
If yes, why?
Are you currently taking any medications?
Yes
No
If yes, please list all of the names and dosages of each medication.
Are you allergic to any medications, products (i.e. latex, etc.) or foods?
Yes
No
If yes, please list all:
Have you ever been treated for or advised that you have any of the following? (Check all that apply)
Speech Disorder
Heart Disorder
Neurological Disorder
Pain in the jaw joint
Stroke
Ulcers
Diabetes
Cancer
Arthritis
Fainting
Hepatitis
ADD/ADHD
Headaches
Eating Disorder
Chronic Cough
Other
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OROFACIAL MYOLOGY HISTORY
Therapy Associates, Inc. 13750 Crosstown Dr. NW Ste 106 Phone: 763-444-8700 Fax: 763-434-0192
Please briefly describe your orthodontic treatment (i.e. palatal expansion followed by braces for X years, oral surgery, tooth extraction, etc.)
Have you had an orthodontic relapse?
Yes
NO
Do you wear a retainer?
Yes
No
Do you suffer from allergies (i.e. pollen, dust, pets/animals, other environmental factors. etc.)?
Yes
NO
If yes, please list allergy and medication taken, if any.
Have you had your tonsils /adenoids removed?
Yes
No
If yes, approximate month/year of surgery:
Do you suffer from any of the following (select all that apply)
Tooth Wear
Gum Inflammation
Periodontal Disease
TMJ Pain
Deviated Septum
Ear Infections
Have you ever had an injury to your involving your: (Select all that apply)
Mouth
Neck
Head
Shoulder
If you select any from above, please describe the injury and treatment.
Do you suffer from any disease or disorder affecting muscle strength or muscle movement (i.e. Cerebral Palsy, Bells Palsy?)
Yes
No
Do you play a musical instrument?
Yes
No
If yes, what instrument(s) and how many hours of practice is done daily?
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OROFACIAL MYOLOGY HISTORY
Therapy Associates, Inc. 13750 Crosstown Dr. NW Ste 106 Phone: 763-444-8700 Fax: 763-434-0192
Do you play any sports?
Yes
No
If yes, what sport(s) and how many hours of practice is done daily?
Do you grind your teeth?
Yes
No
Unsure
Do you have any loose teeth, or notice a change in a tooth and/or bite?
Yes
No
If yes, Please explain.
How often do you brush your teeth?
How do you sleep?
Right Side
Left Side
Stomach
Back
Multiple Positions/Toss and Turn
Do you snore?
Yes
No
Unsure
If yes, is it loud and how often?
Loud
Not Loud
Frequently
Occasionally
Do you suffer from sleep apnea?
Yes
No
If yes, do you use a C-PAP Machine
Yes
No
Do you have any of the following habits? (select all that apply)
Chewing on a pen/pencil
Sucking your tongue
Chewing the inside of your cheeks
Nail biting
Biting your lip
Resting your face on your hand
Chewing your hair
Suck on your finger/thumb
Smack your lips
Lick your lips
Do you breath through your mouth when asleep:
Yes
No
Unsure
Do you breath through your mouth when awake?
Yes
No
Do you frequently get cold sore, blisters, or any other oral lesion.
Yes
No
Do you have a tried jaw, especially in the morning?
Yes
No
Do you hear a click, pop, or grating sound in your jaw joints?
Yes
No
Has your jaw ever locked open or closed?
Yes
No
Have you ever had jaw surgery?
Yes
No
If yes, date of surgery.
What are your goals for orofacial myofunction treatment?
Signature
Date
-
Month
-
Day
Year
Date
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