Myofunctional Intake Form

  • Myofunctional Intake Form

    We ask whether this form is for a child or adult so we can tailor the questions to gather the most relevant information. This helps us provide more accurate care based on the patient's specific needs.
  • Is this form being completed on behalf of a child?*

  • Myofunctional Intake Form

  •  / /
  • Sex:*
  • Format: (000) 000-0000.

  • Medical Information

  • Chief complaint/concern/reason for referral*
  • History of Speech Therapy?*
  • History of Speech Therapy?*
  • Airway/Sleep*
  • [Child] Airway/Sleep*
  • Digestive/Nutritional info*
  • Do you have any concerns with your child's eating behaviours?*
  • Sugary foods / beverages intake daily (none, low, mod or high)*

  • Child Information

  • Child's General Health (Good, Fair or Poor?)*
  • Family History*
  • Have you ever witnessed your child stop breathing during sleep?*
  • Does your child have dark circles or bags under their eyes?*
  • Did you ever hear your child grindding / clenching their teeth at night?*

  • Early Childhood

  • Birth History*
  • Difficulty breast or bottle feeding?*
  • History of reflux*
  • Childhood trauma/injuries*
  • Tongue tie noticed or revised as infant/toddler*
  • Past Habits*
  • Past Habits*
  • Present Habits*

  • Dental / Orthodontic History

  •  - -
  • Would you like an orthodontic referral?*
  •  - -
  • Should be Empty: