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?
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Yes
No
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Myofunctional Intake Form
Patient Full Name
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First Name
Last Name
Birth Date
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Month
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Day
Year
Sex:
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Male
Female
Phone Number
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E-mail
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Medical Information
Chief complaint/concern/reason for referral
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Tongue tie
Tongue thrust
Snoring
Teeth clenching
Orthodontic treatment
Speech concerns
Jaw pain
Mouth breathing
Thumb sucking
Teeth grinding
Migraines
Chewing/feeding/swallowing concerns
Sleep apnea or SDB concerns
Headaches
Other
Please list any healthcare professionals or specialists the patient have seen or are currently seeing. Please include contact info if I have your permission to contact them if needed
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What other type of therapies have the patient tried related to your concerns? Have other therapies been successful? Please describe
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What do you hope to accomplish with Orofacial Myofunctional Therapy?
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Any known medical conditions or diseases (past or present)?
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If Yes then please list | If No then input None
Current supplements / natural products
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If Yes then please list | If No then input None
Any previous surgeries/hospitalizations?
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If Yes then please list | If No then input None
Have the patient been diagnosed with sleep apnea?
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Any Allergies / Sensitivities?
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If Yes then please list | If No then input None
Current medications (prescription or OTC)
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If Yes then please list | If No then input None
Depression / Anxiety / Mental Illness?
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If Yes then please list | If No then input None
ADHD/ADD/Behaviour concerns
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If Yes then please list | If No then input None
Tonsils or adenoids removed?
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If Yes then please list | If No then input None
History of Speech Therapy?
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Present Speech Concerns
Headaches
Migraines
Jaw Pain
Earaches
Ear infections
Tubes in ear
None of the above
History of Speech Therapy?
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Present Speech Concerns
Headaches
Migraines
Jaw Pain
Earaches
Ringing in ears
None of the above
Please describe how often you experience the symptoms selected above
Airway/Sleep
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Difficulty breathing through nose
Asthma/breathing difficulties
Breathe through your mouth - Day
Breathe through your mouth - Night
Previous nasal surgery
Sigh/yawn or take deep breaths often
Frequent sinus colds/sore throats
Had a sleep study
Wear a CPAP or oral sleep appliance
Wear or have been told you should wear a Night Guard
Clenching or grinding teeth - Day
Clenching or grinding teeth - Night
Wake up with sore jaws or teeth or headaches in morning
Snore or breathe loudly during sleep
Trouble falling asleep
Trouble staying asleep
Use the bathroom during the night
Restless during sleep
Sweating in the night
Wake up choking/coughing/feeling like you can't breathe
Frequent nightmares/sleep walking
Wake up with a dry mouth
Wake up feeling refreshed
Wake up feeling tired
Trouble focusing or paying attention during day
Feel fatigued, sleepy or brain fog during day
Fall asleep watching tv
Ofnten need to nap
Fallen asleep while driving
Feel irritable/angry/short temper
None of the above
[Child] Airway/Sleep
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Breathe through your mouth - Day
Breathe through your mouth - Night
Asthma/breathing difficulties
Previous nasal surgery
Frequent sinus colds / sore throats
None of the above
Have the patient seen an ENT doctor for any reason?
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Do you have any concerns with your sleep?
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Do you have any concerns with your child sleep?
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Do you notice excessive drooling(when awake or asleep)
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Where does your child sleep?
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Has your child had a sleep study?
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Does your child wear a CPAP?
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Does your child ever grind their teeth?
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Does your child complain of sore jaws or teeth or headaches in morning?
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When does your child go to bed?
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When does your child wake up for the day?
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Does your child frequently resist going to bed?
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How long does it take your child to fall asleep?
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Does your child wake up through the night?
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Does your child wet the bed or wake up to use the bathroom at night?
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Is your child restless during sleep or sleeping in awkward positions?
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Does your child sweat in the night?
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Do you hear your child coughing or gasping in the night?
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Have you ever witnessed your child stop breathing during sleep?
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Does your child have frequent nightmares or sleep walking?
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Does your child appear well-rested in the morning or still appear or seem tired?
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Does your child have dark circles or bags under their eyes?
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Does your child have trouble focusing or paying attention during day?
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Does your child nap during the day or fall asleep at school?
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Does your child often seem irritable / angry / short temper?
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Digestive/Nutritional info
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Avoidance of certain foods/textures
Picky eating
Messy eating
Fast eating
Slow eating
Trouble swallowing pills
Difficulty chewing and/or swallowing
Chewing with moth open
Difficulty breathing and chewing at same time
Gas/bloating/burping/hiccuping/stomach aches after eating
Gag easily
None of the above
Do you have any concerns with your child's eating behaviours?
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Avoidance of certain foods / textures
Picky eating
Messy / fast / very sloweating
Difficulty chewing and / or swallowing
Chewing with moth open
Large bites / stuffing foodin mouth
Difficulty breathing and chewing at the same time
Choking or gagging on foods / liquids
Complains of stomachaches after eating
Frequent gas / bloating / burping after
None of the above
How many cups of water do you drink daily?
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How many cups of caffeinated beverages do you drink daily?
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Sugary foods / beverages intake daily (none, low, mod or high)
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High
Mod
Low
None
Smoking/Vaping/chewing tobacco? If Yes, How often?
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Alcohol use? If Yes, How often?
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Recreational drug use? If Yes, How often?
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Child Information
Child's General Health (Good, Fair or Poor?)
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Good
Fair
Poor
Family History
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Lives with both parents together
Lives with both parents separately
Other
Guardian Name
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First Name
Last Name
Siblings (Ages) if applicable
Family History of orthodontic treatment or concerns (please describe)
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Family history of mouth breathing or tongue tie?
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Do you have any concerns with your child's sleep?
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When does your child go to bed?
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When does your child wake up for the day?
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Does your child frequently resist going to bed?
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How long does it take your child to fall asleep?
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Have you ever witnessed your child stop breathing during sleep?
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Yes
No
Does your child have dark circles or bags under their eyes?
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Yes
No
Did you ever hear your child grindding / clenching their teeth at night?
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Yes
No
Early Childhood
Birth History
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Complications
Vaccuum
Forceps
Preterm
C-Section
Normal/No complications
Breastfed (how long)
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Bottle fed (how long)
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Tube fed (how long)
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Difficulty breast or bottle feeding?
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Yes
No
History of reflux
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Yes
No
Childhood trauma/injuries
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Yes
No
Tongue tie noticed or revised as infant/toddler
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Yes
No
Childhood allergies/asthma ? Please list
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Past Habits
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Thumb sucking
Finger sucking
Chewing on clothes/blankets/pens
Nail biting
Cheek/lip biting or sucking
Lip licking
Pacifier use
None of the above
Other
Past Habits
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Finger sucking
Chewing on clothes/blankets/pens
Nail biting
Cheek/lip biting or sucking
Lip licking
None of the above
Other
Present Habits
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Thumb sucking
Finger sucking
Chewing on clothes/blankets/pens
Nail biting
Cheek/lip biting or sucking
Lip licking
Pacifier use
None of the above
Other
Dental / Orthodontic History
Name of the Dentist / Dental Office
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When was the patient last dental visit?
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Month
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Day
Year
Have the patient had orthodontic treatment? If Yes, When did they have their treatment?
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Palate expander, head gear, or other appliance used?
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Does the patient have retainers (fixed wires or removable retainers)?
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Have the patient noticed relapse? (shifting of teeth, changes to bite, etc)
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Have the patient had any adult teeth extracted?
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Any Previous jaw surgery?
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Does the patient have a history of cavities or extensive dental treatment?
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Does the patient have chipped, broken or worn teeth?
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Would you like an orthodontic referral?
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Yes
No
Patient/Guardian Signature
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Date
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Month
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Day
Year
Date
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