Oral Dysfunction Self-Check Sheet
Please mark all that apply
Appearance
Chapped lips
Lips not touching
Open-mouth at rest
Crookedor crowded teeth
Long face
Small nose
Uneven nostrils
Deviated septum
Forward head posture
Tired eye
Black circles under eyes
Double chin
Appearance Total Points
Body Health
Frequent sinus infections
Frequent nasal congestion / Rhinitis
Frequent cold / flu / covid / sore throat
Sore throat in the morning
Headaches / Migraines
Shoulder aches
Frequent adenoid infections
Frequent tonsil infections
Body Health Total Points
Sleep and Mental Health
Anxiety
ADHD
Poor concentration
Poor academic performance
Always tired
Waking up with dry mouth
Drool on pillow
Difficulty falling asleep
Frequently waking up at night
Sleep Apnea
Snoring
Upper Airway Resistance Syndrome
CPAP
Sleep and Mental Health Total Points
Dental Health and Swallow Health
Mouth-breathing
Frequent Cavities despite having good home care and frequent visits to the dentist
Gum Disease despite flossing, brushing and frequent teeth cleaning appointments
Bad breath
Habit of thumb sucking, nail biting, resting chin on hands, chewing objects
Over bite, over jet, mandibular protrusion
Previous orthodontic treatment
Wear a retainer
Wear a night guard
Low tongue posture
Tongue - tie
Scalloped tongue
Unable to open mouth more than 2cm
Jaw popping / cracking on opening or closing
Loud chewing
Hard to swallow pills
Food spilling from the mouth
Upset stomach after eating
Need water to swallow
Dental Health and Swallow Health Total Points
What’s Your Total Score
Total Score
If you score 15% or more in any of the sections, we invite you for a complementary assessment.
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