Myofunctional Health Check

1

Name

First Name

Last Name

2

Email* This field is required.

example@example.com

Confirm Email

3

How did you hear about us?* This field is required.

4

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

YESNO

5

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

YESNO

6

Tongue rest on the bottom of the mouth rather than fully against the roof?

YESNO

7

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

YESNO

8

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

YESNO

9

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

YESNO

10

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

YESNO

11

Is noisy or messy eating a common issue during meals?

YESNO

12

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

YESNO

13

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

YESNO

14

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

YESNO

15

Has there been a history of orthodontic treatment?

YESNO

16

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

YESNO

17

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

YESNO

18

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

YESNO

19

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

YESNO

20

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

YESNO

21

Have there been observations of increased irritability or mood swings?

YESNO

22

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

YESNO

23

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

YESNO

24

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

YESNO

25

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

26

Are you interested in potentially improving any of the above conditions?* This field is required.

YESNO

27

Which age group(s) are you seeking support for?* This field is required.(Select all that apply)

Early Childhood (0–4)

School-Age (5–12)

Teens & Adults

28

Have you (or your child) previously participated in a myofunctional therapy program elsewhere that didn't provide the long-term, functional results you were looking for?* This field is required.

No, this is our first time exploring myofunctional therapy.

Yes, we’ve 'done exercises' before, but the symptoms have returned or persisted.

Yes—we are seeking a more comprehensive, foundational approach.

Other

29

Next Steps & Guidance* This field is required.This screening is a guide, not a medical diagnosis. If you (or your child) scored positively on several indicators, a Comprehensive Structural-Functional Evaluation with our IAOM Board Certified team is the recommended next step to address these concerns.

Yes, please contact me.Not yet, I’m just gathering info

30

Phone numberPlease include the best time to reach you

Phone # and Preferred time to call

31

No problem! Would you like to be notified when we release our new Foundational Wellness Resources designed for families who aren't quite ready for full therapy but want to start improving their airway health at home?

YESNO