Myofunctional Health Check

1

Name

First Name

Last Name

2

Email* Dit veld is verplicht.

example@example.com

Confirm Email

3

Do you or your child frequently breathe through the mouth instead of the nose during the day and/or night?

YESNO

4

Are you or your child unable to keep lips comfortably closed when at rest?

YESNO

5

Does your or your child’s tongue rest on the bottom of the mouth rather than fully against the roof?

YESNO

6

Are there any speech difficulties, such as lisping or difficulty pronouncing certain sounds?

YESNO

7

Do you or your child snore or have been diagnosed with sleep apnea?

YESNO

8

Have you noticed any imbalances in facial muscle tone or asymmetrical facial development?

YESNO

9

Do you or your child frequently experience headaches or neck pain?

YESNO

10

Is noisy or messy eating a common issue during meals?

YESNO

11

Are there any issues with jaw pain, face pain, unexplained tooth pain, clicking, or popping of the TMJ (temporomandibular joint)?

YESNO

12

Did you or your child suck your/their thumb or use a pacifier past the age of three?

YESNO

13

Are there any noticeable issues with teeth alignment, such as overcrowding or an open bite?

YESNO

14

Has there been a history of orthodontic treatment?

YESNO

15

Is there recurring alignment issues since orthodontic treatment was complete?(Orthodontic Relapse)

YESNO

16

Do you or your child have difficulty concentrating, which might be linked to sleep issues?

YESNO

17

Are frequent upper respiratory infections, like sinusitis or ear infections, a common issue?

YESNO

18

Is chronic nasal congestion or severe allergies currently affecting breathing, or has this been a chronic issue in the past?

YESNO

19

Are low energy levels during the day a concern, possibly due to poor sleep quality?For children, this often presents as hyperactivity

YESNO

20

Have there been observations of increased irritability or mood swings?

YESNO

21

Are there ongoing issues with dental health, such as gum disease, cavities, broken teeth, or gum recession?

YESNO

22

Do you clench your jaws or grind your teeth during the day or at night?

YESNO

23

Have you ever been told that you have a tongue tie, enlarged tonsils, or adenoids?

YESNO

24

Have you been treated for a tongue tie, enlarged tonsils, or adenoids, but did not know that Orofacial Myofunctional Therapy might be necessary to rehabilitate optimal oral function?

YESNO

25

Are you or your child interested in potentially improving any of the above conditions?

YESNO

26

This quiz is intended as an initial screening and is not a substitute for professional medical advice. If you or your child scored positively on several of these questions, it may be beneficial to schedule a Comprehensive Orofacial Structual-Myofunctional Evaluation with one of our Certified Orofacial Myologists.

Please note that while the questions are based on common indicators of need for myofunctional therapy, they are formulated based on general knowledge and are intended for guidance.

27

Interested in speaking with someone from our office about scheduling a a comprehensive structural-functional evaluation?

Phone # and Preferred time to call